Provider Demographics
NPI:1770543480
Name:GOODNIGHT, JON MARC (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MARC
Last Name:GOODNIGHT
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 1:6600 FISH POND RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2581
Mailing Address - Country:US
Mailing Address - Phone:254-752-9368
Mailing Address - Fax:254-752-2201
Practice Address - Street 1:6600 FISH POND RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2581
Practice Address - Country:US
Practice Address - Phone:254-752-9368
Practice Address - Fax:254-752-2201
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2034207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118777501Medicaid
TXF84787Medicare UPIN
TX878185Medicare ID - Type Unspecified