Provider Demographics
NPI:1922110105
Name:GOODMAN, JACK R (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
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 1:200 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5720
Mailing Address - Country:US
Mailing Address - Phone:504-896-9432
Mailing Address - Fax:504-894-9432
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:504-894-9432
Practice Address - Fax:504-896-9432
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010553208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1133922Medicaid
LA52215Medicare ID - Type Unspecified
B63686Medicare UPIN