Provider Demographics
NPI:1265923189
Name:GOODRUM, JASON (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GOODRUM
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:PO BOX 26499
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 HILL COUNTRY DR STE 101
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6024
Practice Address - Country:US
Practice Address - Phone:830-258-7090
Practice Address - Fax:830-258-7098
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXV3007207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program