Provider Demographics
NPI:1801823083
Name:GOODMAN, CLYDE LEROY (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:LEROY
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C.
Other - Middle Name:LEROY
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4840 BRYANT IRVIN CT.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7680
Mailing Address - Country:US
Mailing Address - Phone:817-335-4549
Mailing Address - Fax:817-377-0970
Practice Address - Street 1:4840 BRYANT IRVIN CT.
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7680
Practice Address - Country:US
Practice Address - Phone:817-335-4549
Practice Address - Fax:817-377-0970
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7984208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034680101Medicaid
TX034680101Medicaid
TX00L975Medicare ID - Type Unspecified