Basic Information
| Provider Information | |||||||||
| NPI: | 1629165436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODIN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 EAST BROADWAY | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652017185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738157118 | ||||||||
| FaxNumber: | 5738157116 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 EAST BROADWAY | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652017185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738157118 | ||||||||
| FaxNumber: | 5738157116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 2006016594 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 200011712 | 05 | MO | MEDICAID |