Provider Demographics
NPI:1902899065
Name:GOODIN, CONNY DALE (MD)
Entity Type:Individual
Prefix:
First Name:CONNY
Middle Name:DALE
Last Name:GOODIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 CROSSFIELD DR STE A
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1845
Mailing Address - Country:US
Mailing Address - Phone:859-873-9843
Mailing Address - Fax:859-873-0972
Practice Address - Street 1:115 CROSSFIELD DR STE A
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1845
Practice Address - Country:US
Practice Address - Phone:859-873-9843
Practice Address - Fax:859-873-0972
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY110031155OtherRAILROAD MEDICARE
KY1404232OtherUMWA
KY64-201593Medicaid
KY000000047824OtherANTHEM BLUE SHIELD
KY611012421DOtherHUMANA
KYD95905OtherBLUEGRASS FAMILY HEALTH
KY0037674OtherMEDICARE - FAYETTE COUNTY HEALTH DEPARTMENT
KY611012421OtherESSENCE
KY0400358OtherUNITED HEALTHCARE
KY1284109OtherUMWA
KY611012421OtherAETNA
KY1404232OtherUMWA
KY0076502Medicare ID - Type UnspecifiedMEDICARE
KY64-201593Medicaid