Provider Demographics
NPI:1629888136
Name:GOODWIN, MARK WILLIAM (MFN, RDN, LD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MFN, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 CHERRY BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-1517
Mailing Address - Country:US
Mailing Address - Phone:937-829-3798
Mailing Address - Fax:
Practice Address - Street 1:2555 S DIXIE DR STE 112
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1532
Practice Address - Country:US
Practice Address - Phone:937-220-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD7271133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic