Provider Demographics
NPI:1659378354
Name:GOODYKOONTZ, TONI B (MD)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:B
Last Name:GOODYKOONTZ
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 1:1400 JOHNSON AVE
Mailing Address - Street 2:SUITE 4H
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1063
Mailing Address - Country:US
Mailing Address - Phone:304-842-1990
Mailing Address - Fax:304-842-4471
Practice Address - Street 1:1400 JOHNSON AVE
Practice Address - Street 2:SUITE 4H
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1063
Practice Address - Country:US
Practice Address - Phone:304-842-1990
Practice Address - Fax:304-842-4471
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV158982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0115011000Medicaid
WV0115011000Medicaid
WVE54263Medicare UPIN