Provider Demographics
NPI:1053095653
Name:GOODWIN, JOHN ROBERT
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GATESHEAD DR
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822
Mailing Address - Country:US
Mailing Address - Phone:908-442-0912
Mailing Address - Fax:
Practice Address - Street 1:4421 VIRGINIA BEACH BLVD
Practice Address - Street 2:#112
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-963-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant