Healthcare Provider Details

I. General information

NPI: 1023376738
Provider Name (Legal Business Name): CLARKE WORLEY GOODMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 ROUND ROCK AVE
ROUND ROCK TX
78681-4004
US

IV. Provider business mailing address

2409 MCCALL RD
AUSTIN TX
78703-3025
US

V. Phone/Fax

Practice location:
  • Phone: 512-341-1000
  • Fax:
Mailing address:
  • Phone: 806-236-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA09703200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR1033
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: