Provider Demographics
NPI:1326157124
Name:GOODMAN, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6254
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:1319 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-3215
Practice Address - Country:US
Practice Address - Phone:402-717-0420
Practice Address - Fax:402-717-6042
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE17235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098684226Medicare PIN
NE098684226Medicare PIN
NE080050055Medicare PIN
NE086032Medicare PIN
NE277037Medicare PIN