Basic Information
Provider Information
NPI: 1003296914
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GOODSELL
FirstName: JEFFREY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X61787CTY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000XMT209559PAN Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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