Provider Demographics
NPI:1528019270
Name:GOODMAN, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:173 E WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-2949
Mailing Address - Country:US
Mailing Address - Phone:530-458-8050
Mailing Address - Fax:530-458-5936
Practice Address - Street 1:173 E WEBSTER ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2949
Practice Address - Country:US
Practice Address - Phone:530-458-8050
Practice Address - Fax:530-458-5936
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2014-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG070755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13380ZMedicare ID - Type Unspecified
CAC68786Medicare UPIN