Basic Information
Provider Information | |||||||||
NPI: | 1306374780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODWIN | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | TATE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ATTN: FAMILY MEDICINE | ||||||||
Address2: | 2080 CHILD STREET | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9045427300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9300 DEWITT LOOP | ||||||||
Address2: |   | ||||||||
City: | FORT BELVOIR | ||||||||
State: | VA | ||||||||
PostalCode: | 220605285 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5712311994 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2017 | ||||||||
LastUpdateDate: | 09/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0116030331 | VA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 171000000X | 0101265465 | VA | N |   | Other Service Providers | Military Health Care Provider |   |
No ID Information.