Provider Demographics
NPI:1609266030
Name:R CHARLES GOODMAN, JR, OD, LLC
Entity Type:Organization
Organization Name:R CHARLES GOODMAN, JR, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:334-750-3831
Mailing Address - Street 1:1110 EASTDALE MALL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-2144
Mailing Address - Country:US
Mailing Address - Phone:334-272-4722
Mailing Address - Fax:334-272-5096
Practice Address - Street 1:1110 EASTDALE MALL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-2144
Practice Address - Country:US
Practice Address - Phone:334-272-4722
Practice Address - Fax:334-272-5096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS729-TA155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL143416Medicaid
AL000058324Medicare PIN
ALU19422Medicare UPIN