Provider Demographics
NPI:1639188642
Name:GOODSON, STEPHANIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:GOODSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:KLEPPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:8001 CHALLIS RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116
Practice Address - Country:US
Practice Address - Phone:810-227-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076764208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4632426Medicaid
MI0H16103372Medicare ID - Type Unspecified
MI4632426Medicaid