Provider Demographics
NPI:1417236431
Name:GOODMAN, DAVID (ABOC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11029 MILL CENTRE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3275
Mailing Address - Country:US
Mailing Address - Phone:410-929-8900
Mailing Address - Fax:410-363-1979
Practice Address - Street 1:11029 MILL CENTRE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3275
Practice Address - Country:US
Practice Address - Phone:410-929-8900
Practice Address - Fax:410-363-1979
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD43276156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician