Healthcare Provider Details

I. General information

NPI: 1770588899
Provider Name (Legal Business Name): THOMAS M GOODWIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S GRAND AVE STE 805
LOS ANGELES CA
90015-3011
US

IV. Provider business mailing address

1640 MARENGO ST STE 505
LOS ANGELES CA
90033-1038
US

V. Phone/Fax

Practice location:
  • Phone: 213-763-1500
  • Fax: 213-763-1505
Mailing address:
  • Phone: 323-221-3270
  • Fax: 323-225-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberG65953
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG65953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: