Healthcare Provider Details

I. General information

NPI: 1518546316
Provider Name (Legal Business Name): MICHELLE FAYE GOODWIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-6000
  • Fax:
Mailing address:
  • Phone: 619-740-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA194540
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberA194540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: