Healthcare Provider Details

I. General information

NPI: 1366744260
Provider Name (Legal Business Name): GEORGE GOODKIN DPM DOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2010
Last Update Date: 11/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE BLDG D12
ALBUQUERQUE NM
87109-1534
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE BLDG D12
ALBUQUERQUE NM
87109-1534
US

V. Phone/Fax

Practice location:
  • Phone: 505-353-1722
  • Fax: 505-797-3566
Mailing address:
  • Phone: 505-353-1722
  • Fax: 505-797-3566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number532
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number254
License Number StateNM

VIII. Authorized Official

Name: DR. GEORGE GOODKIN
Title or Position: PRESIDENT
Credential: DPM DOM
Phone: 505-353-1722