Healthcare Provider Details

I. General information

NPI: 1922091875
Provider Name (Legal Business Name): BONNIE J GOODWIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 MEDICAL LANE
POLLOCKSVILLE NC
28573
US

IV. Provider business mailing address

PO BOX 896206
CHARLOTTE NC
28289-6206
US

V. Phone/Fax

Practice location:
  • Phone: 252-633-1010
  • Fax: 252-224-3071
Mailing address:
  • Phone: 252-633-1010
  • Fax: 252-224-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number27049
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: