Provider Demographics
NPI:1881652915
Name:GOOD, ROGER R (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:R
Last Name:GOOD
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 951339
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75395-1339
Mailing Address - Country:US
Mailing Address - Phone:940-270-5000
Mailing Address - Fax:
Practice Address - Street 1:105 N KEENE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8131
Practice Address - Country:US
Practice Address - Phone:573-499-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL02172085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148449501Medicaid
TX00979HMedicare PIN
TXE59200Medicare UPIN