Provider Demographics
NPI:1437152360
Name:ARCHER-GOODE, CORLIS L (MD)
Entity Type:Individual
Prefix:DR
First Name:CORLIS
Middle Name:L
Last Name:ARCHER-GOODE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CORLIS
Other - Middle Name:L
Other - Last Name:ARCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-3916
Mailing Address - Country:US
Mailing Address - Phone:860-826-4453
Mailing Address - Fax:860-826-6219
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:BLDG B2ND
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:860-826-4453
Practice Address - Fax:860-826-6219
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038810208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1255448155OtherGHMC GROUP NPI
CTO2096535OtherOXFORD
CT01038810OtherCIGNA
CT00138810CT01OtherBCBS & BCFP
CT0V7374OtherHEALTH NET
CT2355107OtherAETNA
CTO2096535OtherOXFORD
CTC01373Medicare ID - Type UnspecifiedGHMC GROUP MEDICARE ID