Healthcare Provider Details

I. General information

NPI: 1932294717
Provider Name (Legal Business Name): MAJE D. GOODWIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MEDICAL PARK RD SUITE 102A
MOORESVILLE NC
28117
US

IV. Provider business mailing address

170 MEDICAL PARK RD SUITE 102A
MOORESVILLE NC
28117
US

V. Phone/Fax

Practice location:
  • Phone: 704-663-5240
  • Fax: 704-663-5399
Mailing address:
  • Phone: 704-663-5240
  • Fax: 704-663-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41338
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-00933
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: