Healthcare Provider Details

I. General information

NPI: 1629888136
Provider Name (Legal Business Name): MARK WILLIAM GOODWIN MFN, RDN, LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 S DIXIE DR STE 112
DAYTON OH
45409-1532
US

IV. Provider business mailing address

831 CHERRY BLOSSOM DR
WEST CARROLLTON OH
45449-1517
US

V. Phone/Fax

Practice location:
  • Phone: 937-220-6611
  • Fax:
Mailing address:
  • Phone: 937-829-3798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLD7271
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD7271
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: