Provider Demographics
NPI:1790434181
Name:GOODMAN, ADAM JACOB (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:JACOB
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 1:1401 CENTERVILLE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4638
Mailing Address - Country:US
Mailing Address - Phone:850-431-5567
Mailing Address - Fax:
Practice Address - Street 1:1401 CENTERVILLE RD STE 107
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4638
Practice Address - Country:US
Practice Address - Phone:850-431-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FL1104115948390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program