Provider Demographics
NPI:1992765044
Name:GOODFELLOW, ROSS JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:JOHN
Last Name:GOODFELLOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-6650
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:699 W COCOA BEACH CSWY
Practice Address - Street 2:SUITE 503
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3577
Practice Address - Country:US
Practice Address - Phone:321-434-6650
Practice Address - Fax:321-868-8396
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10988207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002674000Medicaid
FLDO109YOtherMEDICARE
NJI69286Medicare UPIN
FL002674000Medicaid
NJ122354ATBMedicare PIN
NC808101OtherBLUE MEDICARE
NC0142671OtherNEW JERSEY MEDICAID
FL002674000Medicaid
NJ122354ATBMedicare PIN