Provider Demographics
NPI:1255690905
Name:GOODRIDGE, SOPHIA D (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:D
Last Name:GOODRIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:DELPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 HOSPITAL BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4918
Mailing Address - Country:US
Mailing Address - Phone:470-956-4230
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL BLVD STE 290
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:470-956-4230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52077208800000X
GA82831208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100580160Medicaid