Provider Demographics
NPI:1609018860
Name:GOODMAN, MARK QUINCY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:QUINCY
Last Name:GOODMAN
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 1:1303 NE CUSHING DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-908-1217
Mailing Address - Fax:
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1334
Practice Address - Country:US
Practice Address - Phone:541-548-8131
Practice Address - Fax:541-526-6608
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD160709207P00000X, 207PS0010X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1609018860OtherNPI