Provider Demographics
NPI:1891704177
Name:GOODMAN, ERIC TODD (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:TODD
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 1:8933 ACTIVITY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4427
Mailing Address - Country:US
Mailing Address - Phone:858-653-6130
Mailing Address - Fax:
Practice Address - Street 1:8933 ACTIVITY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4427
Practice Address - Country:US
Practice Address - Phone:858-653-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA772392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A772390Medicaid
CAH25341Medicare UPIN
CAWA77239CMedicare ID - Type Unspecified