Provider Demographics
NPI:1891842696
Name:GOODFRED, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GOODFRED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 S MENDENHALL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-5914
Mailing Address - Country:US
Mailing Address - Phone:901-365-1800
Mailing Address - Fax:901-365-1862
Practice Address - Street 1:3965 S MENDENHALL RD STE 6
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-5914
Practice Address - Country:US
Practice Address - Phone:901-365-1800
Practice Address - Fax:901-365-1862
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN1807208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370244Medicare PIN
TN3001738Medicare UPIN