Healthcare Provider Details

I. General information

NPI: 1437713575
Provider Name (Legal Business Name): ROBERT CHARLES GOODRICH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WAKE FOREST BAPTIST MEDICAL CENTER
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

130 ACORN OAKS CIR APT 222
CHATTANOOGA TN
37405-2166
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2694
  • Fax:
Mailing address:
  • Phone: 615-419-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number2024-02194
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number2024-02194
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: