Provider Demographics
NPI:1356754667
Name:GOODWIN, NICOLE DOREEN (MD)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DOREEN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DOREEN
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25170 HANCOCK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5969
Mailing Address - Country:US
Mailing Address - Phone:951-461-9300
Mailing Address - Fax:951-461-9399
Practice Address - Street 1:25170 HANCOCK AVE STE 200
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-461-9300
Practice Address - Fax:951-461-9399
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA150982208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program