Provider Demographics
NPI:1871542654
Name:GOODWIN, J ROGER (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:ROGER
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:R
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1325 ANDREA ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5852
Mailing Address - Country:US
Mailing Address - Phone:270-781-7212
Mailing Address - Fax:270-781-7772
Practice Address - Street 1:1325 ANDREA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5852
Practice Address - Country:US
Practice Address - Phone:270-781-7212
Practice Address - Fax:270-781-7772
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14457208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64144579Medicaid
D92453Medicare UPIN
KY0986004Medicare PIN