Provider Demographics
NPI:1235111907
Name:GOODMAN, ROBERT EMORY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EMORY
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 1:740 JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4616
Mailing Address - Country:US
Mailing Address - Phone:318-424-9240
Mailing Address - Fax:318-424-0022
Practice Address - Street 1:740 JORDAN ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4616
Practice Address - Country:US
Practice Address - Phone:318-424-9240
Practice Address - Fax:318-424-0022
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15562207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA110043608OtherRAILROAD MEDICARE
LA1348465Medicaid
LA1348465Medicaid
LA57064Medicare ID - Type Unspecified