Provider Demographics
NPI:1770575979
Name:GOODLETT, PAUL A (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:GOODLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:101 STONECREST ROAD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065
Mailing Address - Country:US
Mailing Address - Phone:502-633-5565
Mailing Address - Fax:502-633-5154
Practice Address - Street 1:101 STONECREST ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065
Practice Address - Country:US
Practice Address - Phone:502-633-5565
Practice Address - Fax:502-633-5154
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY36027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000197979OtherANTHEM
KY64029614Medicaid
000000197979OtherANTHEM
1278006Medicare ID - Type Unspecified