Provider Demographics
NPI:1831292051
Name:GOODMAN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9 LIVINGSTON ST
Mailing Address - Street 2:STE 5
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601
Mailing Address - Country:US
Mailing Address - Phone:845-454-0415
Mailing Address - Fax:845-454-0914
Practice Address - Street 1:9 LIVINGSTON ST
Practice Address - Street 2:STE 5
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601
Practice Address - Country:US
Practice Address - Phone:845-454-0415
Practice Address - Fax:845-454-0914
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY86055207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY147049OtherMVP
C13377OtherRAILROAD MEDICARE
258661Medicare ID - Type Unspecified
NY147049OtherMVP