Provider Demographics
NPI:1750321386
Name:GOODWIN, MATTHEW BOREE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BOREE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:719-543-0171
Practice Address - Street 1:300 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2006
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-0171
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO292172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF25221Medicare UPIN