Provider Demographics
NPI:1548439185
Name:LYNN E GOODWIN OD PC
Entity type:Organization
Organization Name:LYNN E GOODWIN OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-863-5258
Mailing Address - Street 1:PO BOX 6006
Mailing Address - Street 2:
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-0056
Mailing Address - Country:US
Mailing Address - Phone:541-863-5258
Mailing Address - Fax:541-863-6000
Practice Address - Street 1:425 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-0056
Practice Address - Country:US
Practice Address - Phone:541-863-5258
Practice Address - Fax:541-863-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2025-01-23
Deactivation Date:2024-04-11
Deactivation Code:
Reactivation Date:2024-05-01
Provider Licenses
StateLicense IDTaxonomies
OR1481ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22617-5Medicaid
ORT67661Medicare UPIN
OR0000PHFPGMedicare PIN
OR0707170001Medicare NSC