Provider Demographics
NPI:1710038161
Name:GOODMAN, JACK ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ANDREW
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 1:4515 POPLAR AVE STE 426
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-7517
Mailing Address - Country:US
Mailing Address - Phone:901-683-6083
Mailing Address - Fax:901-761-2364
Practice Address - Street 1:4515 POPLAR AVE STE 426
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-7517
Practice Address - Country:US
Practice Address - Phone:901-683-6083
Practice Address - Fax:901-761-2364
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000014100207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3010848Medicare ID - Type Unspecified
ARA97505Medicare UPIN