Healthcare Provider Details

I. General information

NPI: 1326002817
Provider Name (Legal Business Name): GREGORY GOODWIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LONGWOOD AVE
BOSTON MA
02115-5711
US

IV. Provider business mailing address

59 MANCHESTER AVE
SOMERSET MA
02726-4043
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number071016
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: