Healthcare Provider Details

I. General information

NPI: 1811917297
Provider Name (Legal Business Name): BLAIR T GOODSELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 EL CAMINO REAL SUITE 5
SIERRA VISTA AZ
85635-2860
US

IV. Provider business mailing address

5750 E HIGHWAY 90 STE 200
SIERRA VISTA AZ
85635-9113
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-3920
  • Fax: 520-452-2218
Mailing address:
  • Phone: 520-458-4335
  • Fax: 520-452-2232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2298
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: