Provider Demographics
NPI:1548214190
Name:GOODNER, ANDY GLEE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:GLEE
Last Name:GOODNER
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 1:901 MONTGOMERY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-2911
Mailing Address - Fax:563-387-3102
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-2911
Practice Address - Fax:563-387-3102
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36751207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1548214190Medicaid
IA1548214190Medicaid
IA121280066Medicare PIN