Provider Demographics
NPI:1740399328
Name:GOLDMAN, MARK P (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 291993
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-1993
Mailing Address - Country:US
Mailing Address - Phone:830-895-7675
Mailing Address - Fax:830-896-9340
Practice Address - Street 1:222 SIDNEY BAKER ST S
Practice Address - Street 2:SUITE 500
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5994
Practice Address - Country:US
Practice Address - Phone:830-895-7675
Practice Address - Fax:830-896-9340
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22476103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098724001Medicaid
TX098724001OtherCHIPS
TX00H51ROtherBLUE CROSS
TXR58184Medicare UPIN
TX00H51RMedicare ID - Type UnspecifiedMEDICARE NUMBER