Provider Demographics
NPI:1316505241
Name:GOODYEAR, CASEY JAMES (MD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:JAMES
Last Name:GOODYEAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 N SCRIMSHAW DR APT 304
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7883
Mailing Address - Country:US
Mailing Address - Phone:701-799-2105
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program