Provider Demographics
NPI:1972514404
Name:GOODWIN, SALVATORE R (MD)
Entity type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:R
Last Name:GOODWIN
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-390-3600
Practice Address - Fax:904-396-1630
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35415207L00000X, 208000000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000213804BMedicaid
FL065144301Medicaid
68238YMedicare PIN
FL065144301Medicaid