Provider Demographics
NPI:1396819165
Name:GOEDEKE, REBECCA A (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:GOEDEKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 NORTHWOODS TRAIL
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074
Mailing Address - Country:US
Mailing Address - Phone:410-374-9391
Mailing Address - Fax:410-871-7967
Practice Address - Street 1:4231 NORTHWOODS TRAIL
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074
Practice Address - Country:US
Practice Address - Phone:410-374-9391
Practice Address - Fax:410-871-7967
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E73359Medicare UPIN