Provider Demographics
NPI:1023019346
Name:GOODMAN, GREG R (MD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5444 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-284-1702
Mailing Address - Fax:801-262-3897
Practice Address - Street 1:5323 S. WOODROW STREET
Practice Address - Street 2:#102
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-713-1010
Practice Address - Fax:801-713-0665
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT179027-12052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0968Medicaid
UTD0968Medicaid
UTF76567Medicare UPIN