Healthcare Provider Details

I. General information

NPI: 1205127982
Provider Name (Legal Business Name): JUSTIN GOODEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10346 E STONEGATE LN STE 100
WICHITA KS
67206-2054
US

IV. Provider business mailing address

10346 E STONEGATE LN STE 100
WICHITA KS
67206-2054
US

V. Phone/Fax

Practice location:
  • Phone: 316-871-0995
  • Fax:
Mailing address:
  • Phone: 316-871-0995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number04-36002
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number04-36002
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: