Healthcare Provider Details

I. General information

NPI: 1922107978
Provider Name (Legal Business Name): CHARLES DRU GOODWIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E MAIN ST STE 102
COLUMBUS OH
43215-5369
US

IV. Provider business mailing address

500 E MAIN ST STE 102
COLUMBUS OH
43215-5369
US

V. Phone/Fax

Practice location:
  • Phone: 614-321-3701
  • Fax: 614-259-6072
Mailing address:
  • Phone: 614-321-3701
  • Fax: 614-259-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35040957
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35040957
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: