Provider Demographics
NPI:1134495666
Name:GOODMAN, IAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:P
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4802 S 109TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5822
Mailing Address - Country:US
Mailing Address - Phone:918-392-1400
Mailing Address - Fax:918-392-1488
Practice Address - Street 1:12455 E 100TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4674
Practice Address - Country:US
Practice Address - Phone:918-272-9464
Practice Address - Fax:918-272-9512
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27449207X00000X
FLME133594207X00000X
OK39030207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14123871OtherCAQH