Healthcare Provider Details

I. General information

NPI: 1053574780
Provider Name (Legal Business Name): RONALD GOODLETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36065 SANTA FE AVE
FORT HOOD TX
76544-5060
US

IV. Provider business mailing address

900 WASHINGTON ROAD ALLGOOD BLDG, 2ND FLR, ORTHOPAEDIC SURGERY
WEST POINT NY
10996
US

V. Phone/Fax

Practice location:
  • Phone: 254-286-7978
  • Fax: 254-286-7628
Mailing address:
  • Phone: 845-938-4205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101246282
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101246282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: