Provider Demographics
NPI:1871330290
Name:GOODKIN, MITCHEL
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:GOODKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WANTAGH AVENUE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:631-316-1007
Mailing Address - Fax:
Practice Address - Street 1:1400 WANTAGH AVENUE
Practice Address - Street 2:SUITE 103
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793
Practice Address - Country:US
Practice Address - Phone:631-316-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007212111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor