Provider Demographics
NPI:1912186412
Name:GOODMAN, MARK THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:T
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MARK T GOODMAN DC
Mailing Address - Street 1:3421 KITSAP WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-2601
Mailing Address - Country:US
Mailing Address - Phone:360-377-1626
Mailing Address - Fax:360-377-1903
Practice Address - Street 1:3421 KITSAP WAY
Practice Address - Street 2:SUITE B
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-2601
Practice Address - Country:US
Practice Address - Phone:360-377-1626
Practice Address - Fax:360-377-1903
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002820111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0042155OtherDEPT. LABOR & INDUS. (WA)
WA383670039OtherPREMERA BLUE CROSS
WA38367003901OtherKITSAP PHYSICIANS SERVICE
WAG06107OtherREGENCE BLUE SHIELD
WA383670039OtherGENERAL INSURANCES