Provider Demographics
NPI:1174500631
Name:GOODMAN, ANDREW M (OD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:4032 CAMPBELL RD
Practice Address - Street 2:SUITE B
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4252
Practice Address - Country:US
Practice Address - Phone:757-877-3956
Practice Address - Fax:757-856-7121
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0618000165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174500631Medicaid
VAP00882544Medicare PIN
T21862Medicare UPIN
VA1174500631Medicaid