Provider Demographics
NPI:1083748966
Name:GOODRICH, SCOTT T (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:GOODRICH
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:833-724-8326
Practice Address - Fax:260-266-8941
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60256427207VG0400X
IN01078092A207VX0201X
WAMC60256427207VX0201X
MN758436207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology