Provider Demographics
NPI:1326081837
Name:GOODMAN, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:1333 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-727-2755
Mailing Address - Fax:631-727-2852
Practice Address - Street 1:1333 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2029
Practice Address - Country:US
Practice Address - Phone:631-727-2755
Practice Address - Fax:631-727-2852
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1580532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA61819Medicare UPIN
NY28D721Medicare PIN