Basic Information
| Provider Information | |||||||||
| NPI: | 1003296914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODSELL | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 KILLINGWORTH RD | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064414370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603458535 | ||||||||
| FaxNumber: | 8603458678 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 KILLINGWORTH RD | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064414370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603458535 | ||||||||
| FaxNumber: | 8603458678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT209559 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 61787 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.