Provider Demographics
NPI:1790205854
Name:GOODMAN, ZACHARY AVITAL (MD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:AVITAL
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 1:6642 CLAYTON RD # 278
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6642 CLAYTON RD # 278
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1602
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018042200208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice