Provider Demographics
NPI:1568442465
Name:GOODMAN, GAIL R (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 SOUTHWESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1732
Mailing Address - Country:US
Mailing Address - Phone:716-972-0279
Mailing Address - Fax:716-972-0273
Practice Address - Street 1:3675 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1732
Practice Address - Country:US
Practice Address - Phone:716-972-0279
Practice Address - Fax:716-972-0273
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194330208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010065904OtherUNIVERA
NY01477605Medicaid
NY040426002662OtherFIDELIS
NY1211151OtherIHA
NY147716DLOtherPREFERRED CARE
NY479993OtherWELLCARE
NY000524370006OtherBC/BS
NY147716DLOtherPREFERRED CARE
NYDD3575Medicare PIN