Healthcare Provider Details

I. General information

NPI: 1811489180
Provider Name (Legal Business Name): NJ GOODWIN DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2018
Last Update Date: 06/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12260 TAMIAMI TRL E STE 102
NAPLES FL
34113-7937
US

IV. Provider business mailing address

12260 TAMIAMI TRL E STE 102
NAPLES FL
34113-7937
US

V. Phone/Fax

Practice location:
  • Phone: 239-692-9096
  • Fax:
Mailing address:
  • Phone: 813-690-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS11292
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberOS11292
License Number StateFL

VIII. Authorized Official

Name: NANCY J GOODWIN
Title or Position: OWNER
Credential: DO
Phone: 239-692-9096