Basic Information
| Provider Information | |||||||||
| NPI: | 1194786384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | VITTUM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9521 BOTTLE CREEK LN | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891170501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023637577 | ||||||||
| FaxNumber: | 7023637577 | ||||||||
| Practice Location | |||||||||
| Address1: | 2031 N BUFFALO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023833750 | ||||||||
| FaxNumber: | 7022563231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9462 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2019609 | 05 | NV | MEDICAID |