Healthcare Provider Details

I. General information

NPI: 1629165436
Provider Name (Legal Business Name): JASON A. GOODIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 EAST BROADWAY SUITE 280
COLUMBIA MO
65201-7185
US

IV. Provider business mailing address

1705 EAST BROADWAY SUITE 280
COLUMBIA MO
65201-7185
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-7119
  • Fax: 573-815-7116
Mailing address:
  • Phone: 573-815-7119
  • Fax: 573-815-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2006016594
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: