Provider Demographics
NPI:1629005780
Name:GOODMAN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:2360 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-3051
Mailing Address - Country:US
Mailing Address - Phone:562-981-6856
Mailing Address - Fax:562-426-7792
Practice Address - Street 1:3200 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-5062
Practice Address - Country:US
Practice Address - Phone:562-933-2000
Practice Address - Fax:562-494-7792
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA31080208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310800Medicaid
CA00A310800Medicaid