Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 61787 | CT |
N | 207Q00000X | Family Doctor | MT209559 | PA |
NPI | 1003296914 |
---|---|
Provider Name | Jeffrey Goodsell |
First Address | Higganum, CT 06441-4370 |
Second Address | Higganum, CT 06441-4370 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2015 |
Last Update Date | 27/08/2018 |