Provider Demographics
NPI:1558322446
Name:GOODWIN, MARY K (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9291
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67277-0291
Mailing Address - Country:US
Mailing Address - Phone:316-721-4669
Mailing Address - Fax:
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:KS
Practice Address - Zip Code:67025-8844
Practice Address - Country:US
Practice Address - Phone:316-540-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-18112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D79492Medicare UPIN
003719180OtherMEDICARE
KS100083070TMedicaid
KS110173177Medicare PIN
KS110173177Medicare PIN