Provider Demographics
NPI:1285683839
Name:GOODRICH, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:E
Other - Last Name:GOODRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4140 W MEMORIAL RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8366
Mailing Address - Country:US
Mailing Address - Phone:405-486-8041
Mailing Address - Fax:405-486-8044
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:SUITE 601
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-486-8041
Practice Address - Fax:405-486-8044
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK108762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE11689Medicare UPIN