MEDICARE: MICHAEL JON GOODWIN LDO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	1913	FL

General Provider Information

NPI Number	:	1346110186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JON GOODWIN LDO

Provider Business Mailing Address
First Line	:	1107 VENETIAN HARBOR DR NE
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-1916
Country	:	US
Telephone Number	:	727-421-8133
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 VENETIAN HARBOR DR NE
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-1916
Country	:	US
Telephone Number	:	727-421-8133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2025
Last Update Date	:	11/07/2025

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