Provider Demographics
NPI:1487632881
Name:GOODSON, MARK ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:GOODSON
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 1:114 WELTON WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9163
Mailing Address - Country:US
Mailing Address - Phone:704-664-5766
Mailing Address - Fax:704-664-9311
Practice Address - Street 1:114 WELTON WAY STE A
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9251
Practice Address - Country:US
Practice Address - Phone:704-664-5766
Practice Address - Fax:704-664-9311
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-013732081P2900X
NC9701373208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790243UMedicaid
NC2244486BOtherMEDICARE INDIVIDUAL
NCG54400OtherUPIN
NC790243UMedicaid