Basic Information
| Provider Information | |||||||||
| NPI: | 1548251101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MEADOWCREST ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700565255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043917650 | ||||||||
| FaxNumber: | 5043947344 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MEADOWCREST ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700565255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043917650 | ||||||||
| FaxNumber: | 5043947344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 015145 | LA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1337994 | 05 | LA | MEDICAID |