Provider Demographics
NPI:1952387490
Name:GOODWIN, STEPHEN (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 AMELIA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-5478
Mailing Address - Country:US
Mailing Address - Phone:803-531-0061
Mailing Address - Fax:803-531-0095
Practice Address - Street 1:1230 AMELIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-5478
Practice Address - Country:US
Practice Address - Phone:803-531-0061
Practice Address - Fax:803-531-0095
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC584156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDV5842Medicaid