Provider Demographics
NPI:1902845134
Name:GOODMAN, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:13188 N 103RD DR
Mailing Address - Street 2:STE 206
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3064
Mailing Address - Country:US
Mailing Address - Phone:623-972-3001
Mailing Address - Fax:623-933-3045
Practice Address - Street 1:13188 N 103RD DR
Practice Address - Street 2:STE 206
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3064
Practice Address - Country:US
Practice Address - Phone:623-972-3001
Practice Address - Fax:623-933-3045
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33921208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ957912Medicaid
AZZ142916Medicare PIN