Provider Demographics
NPI:1245812304
Name:GOODWIN, LUCAS (DO)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:GOODWIN
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 1:4111 1ST AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1345
Mailing Address - Country:US
Mailing Address - Phone:304-755-4797
Mailing Address - Fax:
Practice Address - Street 1:4111 1ST AVE STE 3
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1345
Practice Address - Country:US
Practice Address - Phone:304-755-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine