=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164043386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDALL LYN GOODYEAR MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2020
-----------------------------------------------------
Last Update Date | 06/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3705 MEDICAL PKWY STE 120
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-1022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-458-2141
-----------------------------------------------------
Fax | 512-458-4824
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3705 MEDICAL PKWY STE 120
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-1022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-458-2141
-----------------------------------------------------
Fax | 512-458-2141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207WX0200X
-----------------------------------------------------
Taxonomy Name | Ophthalmic Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | U8332
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------