Provider Demographics
NPI:1285616870
Name:GOODWIN, ANDREA D (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:D
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:D
Other - Last Name:DUKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4715 24TH PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1686
Mailing Address - Country:US
Mailing Address - Phone:601-696-6736
Mailing Address - Fax:601-696-6778
Practice Address - Street 1:4715 24TH PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305
Practice Address - Country:US
Practice Address - Phone:601-696-6736
Practice Address - Fax:601-696-6778
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17693207Q00000X, 207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00071956OtherRAILROAD MEDICARE
MS00755091Medicaid
H98555Medicare UPIN
MS00755091Medicaid