Provider Demographics
NPI:1508848433
Name:GOODMAN, MASON R (MD)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:R
Last Name:GOODMAN
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD STE 230
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1252
Practice Address - Country:US
Practice Address - Phone:317-962-5820
Practice Address - Fax:317-962-3916
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024689A207K00000X, 207KA0200X, 207RG0300X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000081345OtherBC/BS
IN267030315OtherMEDICARE PTAN
IN100062950Medicaid
290006483OtherRAILROAD MEDICARE PIN
CI0473OtherRAILROAD GROUP
290006483OtherRAILROAD MEDICARE PIN
INE03581Medicare UPIN
IN100062950Medicaid