Provider Demographics
NPI:1710071196
Name:GOODLUCK, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GOODLUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91224
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-1224
Mailing Address - Country:US
Mailing Address - Phone:505-924-5840
Mailing Address - Fax:505-924-5841
Practice Address - Street 1:4600 MONTGOMERY BLVD NE
Practice Address - Street 2:BLDG B, STE 100
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-924-5840
Practice Address - Fax:505-924-5841
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-251202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81783311Medicaid
$$$$$$$$$PMedicare PIN
G54203Medicare UPIN