Provider Demographics
NPI:1548786676
Name:GOODFRIEND, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:GOODFRIEND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12748-0678
Mailing Address - Country:US
Mailing Address - Phone:845-428-1678
Mailing Address - Fax:
Practice Address - Street 1:4 DURR ROAD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12748
Practice Address - Country:US
Practice Address - Phone:845-428-1678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY993386984343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04564518Medicaid