Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | C-4716 | AR |
Y | 208600000X | Surgeon | C-4716 | AR |
NPI | 1013960442 |
---|---|
Provider Name | Raymond C. Goodman JR. |
First Address | Fort Smith, AR 72903-3219 |
Second Address | Fort Smith, AR 72903-4073 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2006 |
Last Update Date | 21/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100082220A | OK MEDICAID (01) | AR |
105795001 | (05) | AR |
51933 | AR BLUECROSS BLUESHIELD (01) | AR |
D79448 | (02) | AR |