Provider Demographics
NPI:1730459686
Name:GOODHUE, KEVIN LEE JR (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:GOODHUE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 SOUTH ORANGE BLOSSOM TRAIL
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703
Mailing Address - Country:US
Mailing Address - Phone:407-880-0335
Mailing Address - Fax:407-880-6732
Practice Address - Street 1:730 SOUTH ORANGE BLOSSOM TRAIL
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703
Practice Address - Country:US
Practice Address - Phone:407-880-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1677152W00000X
FLOPC4705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009942600Medicaid