Provider Demographics
NPI:1194801316
Name:F MARK GOODWIN MD PA
Entity type:Organization
Organization Name:F MARK GOODWIN MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-688-8401
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-0907
Mailing Address - Country:US
Mailing Address - Phone:863-688-8401
Mailing Address - Fax:863-682-3659
Practice Address - Street 1:2000 E EDGEWOOD DR
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3653
Practice Address - Country:US
Practice Address - Phone:863-688-8401
Practice Address - Fax:863-682-3659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0546930001Medicare NSC