Provider Demographics
NPI:1952661688
Name:GOODWIN, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:BLALOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5300 N. INDEPENDENCE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-844-4300
Mailing Address - Fax:405-844-4333
Practice Address - Street 1:1700 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3022
Practice Address - Country:US
Practice Address - Phone:405-844-4300
Practice Address - Fax:405-844-4333
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29248208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics