Provider Demographics
NPI:1821522608
Name:GOODMAN, BRITTON (DO)
Entity Type:Individual
Prefix:
First Name:BRITTON
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 E SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5419
Mailing Address - Country:US
Mailing Address - Phone:480-893-2345
Mailing Address - Fax:480-926-0495
Practice Address - Street 1:2345 E SOUTHERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5419
Practice Address - Country:US
Practice Address - Phone:804-893-2345
Practice Address - Fax:480-926-0495
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ008113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ005823Medicaid