Provider Demographics
NPI:1629052386
Name:GOODMAN, CAROL ANN (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-5110
Mailing Address - Country:US
Mailing Address - Phone:812-456-9736
Mailing Address - Fax:812-456-0140
Practice Address - Street 1:1909 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-5110
Practice Address - Country:US
Practice Address - Phone:812-456-9736
Practice Address - Fax:812-456-0140
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200042720AMedicare ID - Type Unspecified
IN177540AMedicare ID - Type Unspecified
ING08475Medicare UPIN