Provider Demographics
NPI:1760072896
Name:GOODMAN, PHILLLIP
Entity Type:Individual
Prefix:
First Name:PHILLLIP
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MAIN STREET SHOP CENTRE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165
Mailing Address - Country:US
Mailing Address - Phone:315-329-1904
Mailing Address - Fax:
Practice Address - Street 1:204 MAIN STREET SHOP CTR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1454
Practice Address - Country:US
Practice Address - Phone:315-539-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010346156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician