Provider Demographics
NPI:1790893394
Name:GOODMAN, GEORGE E (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:E
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 EDEN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6261
Mailing Address - Country:US
Mailing Address - Phone:405-245-9333
Mailing Address - Fax:
Practice Address - Street 1:3624 EDEN DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-6261
Practice Address - Country:US
Practice Address - Phone:405-245-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2128152W00000X
IL046.010017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U51907Medicare UPIN