Healthcare Provider Details

I. General information

NPI: 1902845134
Provider Name (Legal Business Name): JONATHAN GOODMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13188 N 103RD DR STE 206
SUN CITY AZ
85351-3064
US

IV. Provider business mailing address

13188 N 103RD DR STE 206
SUN CITY AZ
85351-3064
US

V. Phone/Fax

Practice location:
  • Phone: 623-972-3001
  • Fax: 623-933-3045
Mailing address:
  • Phone: 623-972-3001
  • Fax: 623-933-3045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33921
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: