Provider Demographics
NPI:1932498482
Name:GOODMAN, PAUL
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 SARVIS AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1394
Mailing Address - Country:US
Mailing Address - Phone:301-277-4844
Mailing Address - Fax:301-927-3221
Practice Address - Street 1:5711 SARVIS AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1394
Practice Address - Country:US
Practice Address - Phone:301-277-4844
Practice Address - Fax:301-927-3221
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD79841207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD79841OtherMEDICAL LICENSE