Provider Demographics
NPI:1710114558
Name:KEISHA GOODISON DO, PA
Entity Type:Organization
Organization Name:KEISHA GOODISON DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:ADAMA
Authorized Official - Last Name:GOODISON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-366-3425
Mailing Address - Street 1:100 E SAMPLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-3554
Mailing Address - Country:US
Mailing Address - Phone:954-366-3425
Mailing Address - Fax:954-366-3510
Practice Address - Street 1:100 E SAMPLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064
Practice Address - Country:US
Practice Address - Phone:954-366-3425
Practice Address - Fax:954-366-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care