Provider Demographics
NPI:1992913941
Name:GOODWICH, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:GOODWICH
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 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-2216
Practice Address - Country:US
Practice Address - Phone:239-274-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008257207U00000X
FLME 101513207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL281368800Medicaid
FL281368800Medicaid
FLAQ951UMedicare PIN
FLAQ951TMedicare PIN
FLAQ951YMedicare PIN
FLAQ951ZMedicare PIN