Provider Demographics
NPI:1255658308
Name:GOODMAN, RACHEL WOLFE
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:WOLFE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:LEE
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1010 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2724
Mailing Address - Country:US
Mailing Address - Phone:505-367-0340
Mailing Address - Fax:505-367-0326
Practice Address - Street 1:1010 SPRUCE ST.
Practice Address - Street 2:PRESBYTERIAN MEDICAL GROUP - ESPANOLA
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-367-0340
Practice Address - Fax:505-367-0326
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0100207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program