Healthcare Provider Details

I. General information

NPI: 1992913941
Provider Name (Legal Business Name): RONALD GOODWICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 VERONICA S SHOEMAKER BLVD
FORT MYERS FL
33916-2216
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD ATTN: CREDENTIALING DEPT
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 239-274-8200
  • Fax:
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberC1-0008257
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME 101513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: