Provider Demographics
NPI:1578638391
Name:GOODMAN, MARK E
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:GOODMAN
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 1:103 CONIFER CT
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-9195
Mailing Address - Country:US
Mailing Address - Phone:765-664-9014
Mailing Address - Fax:
Practice Address - Street 1:1709 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348-1359
Practice Address - Country:US
Practice Address - Phone:765-348-4197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000428A2255A2300X
IN06003535A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer