Provider Demographics
NPI:1861490492
Name:GOODMAN, JAY S (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:S
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SAINT PAUL PL
Mailing Address - Street 2:SUITE 300-T DEPARTMENT OF MEDICINE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:410-332-9692
Mailing Address - Fax:410-962-8391
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:SUITE 300-T DEPARTMENT OF MEDICINE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9692
Practice Address - Fax:410-962-8391
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02153207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3690Medicare ID - Type Unspecified
MDD76237Medicare UPIN