Provider Demographics
NPI:1528224334
Name:GOODMAN, KEVIN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAVID
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-763-6412
Mailing Address - Fax:607-763-5854
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6412
Practice Address - Fax:607-763-5854
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT189347207P00000X
NY260881207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03349066Medicaid
NYJ400048573Medicare PIN