Provider Demographics
NPI:1699740738
Name:GOODWIN, STEPHANIE L (DO)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TAUGHANNOCK BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3251
Mailing Address - Country:US
Mailing Address - Phone:607-269-0100
Mailing Address - Fax:607-269-0140
Practice Address - Street 1:310 TAUGHANNOCK BLVD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3251
Practice Address - Country:US
Practice Address - Phone:607-269-0100
Practice Address - Fax:607-269-0140
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0008116207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010105340Medicaid
005884533Medicare ID - Type Unspecified
VA010105340Medicaid