Healthcare Provider Details

I. General information

NPI: 1942940473
Provider Name (Legal Business Name): DUSTIN RYAN GOODWIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N. CIVIC SQ.
GOODYEAR AZ
85395
US

IV. Provider business mailing address

1800 N CIVIC SQ STE 220
GOODYEAR AZ
85395-2391
US

V. Phone/Fax

Practice location:
  • Phone: 623-465-6506
  • Fax:
Mailing address:
  • Phone: 623-465-6506
  • Fax: 623-474-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number76782
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: