Provider Demographics
NPI:1174168884
Name:GOODMAN, DAVID SCOTT
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:SCOTT
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-3012
Mailing Address - Country:US
Mailing Address - Phone:518-463-1211
Mailing Address - Fax:518-463-3585
Practice Address - Street 1:301 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-3012
Practice Address - Country:US
Practice Address - Phone:518-463-1211
Practice Address - Fax:518-463-3585
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1379152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty