Provider Demographics
NPI:1932423951
Name:GOYENECHE, NICHOLAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:GOYENECHE
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:PO BOX 732892
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8880 NAVARRE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-3614
Practice Address - Country:US
Practice Address - Phone:850-908-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2051232081S0010X
FLME1590932081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2106601Medicaid
FL116491300Medicaid
MS05658760Medicaid