Provider Demographics
NPI:1760627343
Name:GOOMISHIAN, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GOOMISHIAN
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 1:1415 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4663
Mailing Address - Country:US
Mailing Address - Phone:510-749-0282
Mailing Address - Fax:
Practice Address - Street 1:1415 BROADWAY
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4663
Practice Address - Country:US
Practice Address - Phone:510-749-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator