Provider Demographics
NPI:1770588899
Name:GOODWIN, THOMAS M (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
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 1:1640 MARENGO ST
Mailing Address - Street 2:STE 505
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1038
Mailing Address - Country:US
Mailing Address - Phone:323-221-3270
Mailing Address - Fax:323-225-6284
Practice Address - Street 1:1400 S GRAND AVE
Practice Address - Street 2:STE 805
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3011
Practice Address - Country:US
Practice Address - Phone:213-763-1500
Practice Address - Fax:213-763-1505
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65953207VM0101X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G659530Medicaid
CA00G659530OtherBLUE SHIELD
CA00G659530OtherBLUE SHIELD
CAE67708Medicare UPIN