Provider Demographics
NPI:1336133925
Name:GOODMAN, TOBIAS MARK (MD)
Entity Type:Individual
Prefix:
First Name:TOBIAS
Middle Name:MARK
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 1:41 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-3113
Mailing Address - Country:US
Mailing Address - Phone:401-596-7736
Mailing Address - Fax:401-596-6368
Practice Address - Street 1:41 EAST AVE
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-3113
Practice Address - Country:US
Practice Address - Phone:401-596-7736
Practice Address - Fax:401-596-6368
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI4530208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI900402Medicaid
C90214Medicare UPIN