Provider Demographics
NPI:1811034234
Name:GOODMAN WILSON, GITTLE G (MD)
Entity Type:Individual
Prefix:
First Name:GITTLE
Middle Name:G
Last Name:GOODMAN WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GITTLE
Other - Middle Name:G
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2616 MERIDIAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2409
Mailing Address - Country:US
Mailing Address - Phone:360-715-9500
Mailing Address - Fax:360-752-1407
Practice Address - Street 1:2616 MERIDIAN ST STE 101
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2409
Practice Address - Country:US
Practice Address - Phone:360-715-9500
Practice Address - Fax:360-752-1407
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
861079160OtherTAX ID
WABG6475114OtherDEA
861079160OtherTAX ID
H05057Medicare UPIN