Provider Demographics
NPI:1245337302
Name:GOODING, JUSTIN MATHIAS (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MATHIAS
Last Name:GOODING
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 1:1955 CITRACADO PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-4111
Mailing Address - Country:US
Mailing Address - Phone:760-940-4055
Mailing Address - Fax:
Practice Address - Street 1:4002 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4506
Practice Address - Country:US
Practice Address - Phone:760-940-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG789892085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG69274Medicare UPIN