Healthcare Provider Details

I. General information

NPI: 1477858769
Provider Name (Legal Business Name): JONATHAN PAUL GOODWIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 03/29/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 BAPTIST HEALTH DR STE 301
LITTLE ROCK AR
72205-6230
US

IV. Provider business mailing address

22 BERNEY WAY DR
LITTLE ROCK AR
72223-9112
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-4488
  • Fax: 870-536-9020
Mailing address:
  • Phone: 870-612-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000002929
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2668
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: