Provider Demographics
NPI:1619000940
Name:RAYMOND C. GOODMAN, O.D., P.A.
Entity Type:Organization
Organization Name:RAYMOND C. GOODMAN, O.D., P.A.
Other - Org Name:EYECARE CENTER OF GOODING PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-934-4856
Mailing Address - Street 1:317 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1302
Mailing Address - Country:US
Mailing Address - Phone:208-934-4856
Mailing Address - Fax:208-934-5818
Practice Address - Street 1:317 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1302
Practice Address - Country:US
Practice Address - Phone:208-934-4856
Practice Address - Fax:208-934-5818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDA2306OtherRAILROAD MEDICARE
ID4776340001OtherDMERC
ID4776340001OtherDMERC
ID1375284Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
ID4776340001Medicare NSC