Provider Demographics
NPI:1982838264
Name:GOODRICH, ROBERT J (MD CST)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:MD CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 MESQUITE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5772
Mailing Address - Country:US
Mailing Address - Phone:928-854-7962
Mailing Address - Fax:928-854-7963
Practice Address - Street 1:1930 MESQUITE AVE STE 2
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5772
Practice Address - Country:US
Practice Address - Phone:928-854-7962
Practice Address - Fax:928-854-7963
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16984207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine