Basic Information
| Provider Information | |||||||||
| NPI: | 1992765044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODFELLOW | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214346650 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 699 W COCOA BEACH CSWY | ||||||||
| Address2: | SUITE 503 | ||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214346650 | ||||||||
| FaxNumber: | 3218688396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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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 | 207RI0011X | OS10988 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | DO109Y | 01 | FL | MEDICARE | OTHER | 002674000 | 05 | FL | MEDICAID |