Provider Demographics
NPI:1043218159
Name:GOODMAN, GLEN K (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:K
Last Name:GOODMAN
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 1:87 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2514
Mailing Address - Country:US
Mailing Address - Phone:203-574-2020
Mailing Address - Fax:
Practice Address - Street 1:87 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2514
Practice Address - Country:US
Practice Address - Phone:203-574-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46944207W00000X
CT67111207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0177555Medicaid
MAC20273Medicare ID - Type Unspecified
MA0177555Medicaid