Provider Demographics
NPI:1568496008
Name:GOOD, WALLACE HANNA JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:HANNA
Last Name:GOOD
Suffix:JR
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:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-0386
Mailing Address - Country:US
Mailing Address - Phone:802-452-5817
Mailing Address - Fax:
Practice Address - Street 1:12 LAKEMOUNT DR
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-0386
Practice Address - Country:US
Practice Address - Phone:802-524-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006834207L00000X
NY144954207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT06375OtherBLUE SHIELD
NY01053034Medicaid
VT0006375Medicaid
VT86095OtherMVP
VT25K050052Medicare ID - Type UnspecifiedTRAVELERS RAILROAD
NYCC4950Medicare ID - Type Unspecified
VT06375OtherBLUE SHIELD
VTVT6375Medicare ID - Type Unspecified