Provider Demographics
NPI:1679556633
Name:GOODMAN, MATTHEW MORTENSEN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MORTENSEN
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 1:13261 CROMWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4705
Mailing Address - Country:US
Mailing Address - Phone:714-955-1214
Mailing Address - Fax:623-259-6754
Practice Address - Street 1:180 NEWPORT CENTER DR STE 158
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-0934
Practice Address - Country:US
Practice Address - Phone:949-719-1800
Practice Address - Fax:949-719-1810
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53769207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G537690Medicaid
E48091Medicare UPIN
CAWG53769CMedicare PIN
CA00G537690Medicaid