Provider Demographics
NPI:1841386471
Name:GOODMAN, THEODORE AVRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:AVRAM
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7700 FOLSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2608
Mailing Address - Country:US
Mailing Address - Phone:916-386-3645
Mailing Address - Fax:916-386-3613
Practice Address - Street 1:7700 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826
Practice Address - Country:US
Practice Address - Phone:916-386-3645
Practice Address - Fax:916-386-3050
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG359732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG35973OtherMEDICAL LICENSE
CAA46537Medicare UPIN
CAZZZ22535ZMedicare ID - Type Unspecified