Provider Demographics
NPI:1811917297
Name:GOODSELL, BLAIR T (DO)
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:T
Last Name:GOODSELL
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:5750 E HIGHWAY 90
Mailing Address - Street 2:STE 200
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-9113
Mailing Address - Country:US
Mailing Address - Phone:520-458-4335
Mailing Address - Fax:520-452-2232
Practice Address - Street 1:302 EL CAMINO REAL
Practice Address - Street 2:SUITE 5
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2860
Practice Address - Country:US
Practice Address - Phone:520-459-3920
Practice Address - Fax:520-452-2218
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-06-09
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Provider Licenses
StateLicense IDTaxonomies
AZ2298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ280214Medicaid
AZ280214Medicaid
WCKMG05Medicare ID - Type Unspecified