Provider Demographics
NPI:1568481356
Name:GOODHART, GLENN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:LEE
Last Name:GOODHART
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:40100 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-5906
Practice Address - Country:US
Practice Address - Phone:863-422-4971
Practice Address - Fax:863-419-2264
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-43462207R00000X
GAD29594174400000X
FLME116577207R00000X
GA19386207R00000X
PAMD034685L208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00213694AMedicaid
GA019386OtherLICENSE NUMBER
GA85001797GOtherGEORGIA BETTER HEALTHCARE
GA854101OtherCIGNA ID NUMBER
GA2027755OtherAETNA US GROUP NUMBER
GA9206456OtherUNITED HEALTHCARE ID
GA52241370OtherBCBS PROVIDER NUMBER
GA52241370OtherSTATE HEALTH BENEFIT
GAAG8285822OtherDEA NUMBER
GA2027755OtherAETNA US GROUP NUMBER
GA00213694AMedicaid