MEDICARE: DR. TINA L GOODSON M.D.

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	2084P0800X	Psychiatry Physician	LL1778	NV

General Provider Information

NPI Number	:	1467650358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TINA L GOODSON M.D.

Provider Business Mailing Address
First Line	:	2000 GRAVEL HILL ST
Second Line	:	UNIT 203
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-6970
Country	:	US
Telephone Number	:	702-538-8076
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 W CHARLESTON BLVD
Second Line	:	SUITE 78
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1921
Country	:	US
Telephone Number	:	702-968-5084
Fax Number	:

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

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	07/08/2007

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