Provider Demographics
NPI:1396713434
Name:GOODWIN, MARK CLIFFORD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CLIFFORD
Last Name:GOODWIN
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 1:36977 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BURNEY
Mailing Address - State:CA
Mailing Address - Zip Code:96013-4067
Mailing Address - Country:US
Mailing Address - Phone:530-335-3651
Mailing Address - Fax:530-335-3632
Practice Address - Street 1:36977 PARK AVE
Practice Address - Street 2:
Practice Address - City:BURNEY
Practice Address - State:CA
Practice Address - Zip Code:96013-4067
Practice Address - Country:US
Practice Address - Phone:530-335-3651
Practice Address - Fax:530-335-3632
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H54234Medicare UPIN