Provider Demographics
NPI:1942285259
Name:GOODRICH, STEVEN D (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:GOODRICH
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:PO BOX 78429
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-8429
Mailing Address - Country:US
Mailing Address - Phone:314-251-6478
Mailing Address - Fax:614-251-5817
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE 585A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6478
Practice Address - Fax:614-251-5817
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2F98207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202217436Medicaid
MO202217436Medicaid
MO000094498Medicare PIN