Healthcare Provider Details

I. General information

NPI: 1245337302
Provider Name (Legal Business Name): JUSTIN MATHIAS GOODING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 VISTA WAY
OCEANSIDE CA
92056-4506
US

IV. Provider business mailing address

1955 CITRACADO PKWY STE 100
ESCONDIDO CA
92029-4111
US

V. Phone/Fax

Practice location:
  • Phone: 760-940-4055
  • Fax:
Mailing address:
  • Phone: 760-940-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG78989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: