Provider Demographics
NPI:1407859739
Name:GOODMAN, RAYMOND C (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:C
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1302
Mailing Address - Country:US
Mailing Address - Phone:208-934-4856
Mailing Address - Fax:208-934-5818
Practice Address - Street 1:317 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1302
Practice Address - Country:US
Practice Address - Phone:208-934-4856
Practice Address - Fax:208-934-5818
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010138989OtherREGENCE BLUE SHIELD
ID806370300Medicaid
IDV050-0OtherBLUE CROSS
IDP00013176Medicare PIN
ID1594056Medicare ID - Type Unspecified
ID806370300Medicaid
ID4776340001Medicare NSC