Provider Demographics
NPI:1821196692
Name:GOODWIN, THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1711
Mailing Address - Country:US
Mailing Address - Phone:304-872-1006
Mailing Address - Fax:
Practice Address - Street 1:1018 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1711
Practice Address - Country:US
Practice Address - Phone:304-872-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV775111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2202068000Medicaid
WVU92365Medicare UPIN
WV4094941Medicare PIN