Basic Information
| Provider Information | |||||||||
| NPI: | 1730839002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | BRADY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156432682 | ||||||||
| FaxNumber: | 5156435802 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156432682 | ||||||||
| FaxNumber: | 5156435802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2022 | ||||||||
| LastUpdateDate: | 06/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | IA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | R-12606 | IA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.