Provider Demographics
NPI:1750541009
Name:GOODWIN, SIDNEY BRENT (OD)
Entity type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:BRENT
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3443
Mailing Address - Country:US
Mailing Address - Phone:719-467-5143
Mailing Address - Fax:
Practice Address - Street 1:2776 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4010
Practice Address - Country:US
Practice Address - Phone:719-275-1523
Practice Address - Fax:719-275-6925
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUOL039152W00000X
CO3201152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist