Provider Demographics
NPI:1972581841
Name:GOODMAN, GARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3520 E 15TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8938
Mailing Address - Country:US
Mailing Address - Phone:970-669-9100
Mailing Address - Fax:970-669-0440
Practice Address - Street 1:3520 E 15TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8938
Practice Address - Country:US
Practice Address - Phone:970-669-9100
Practice Address - Fax:970-669-0440
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO36761208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01367614Medicaid
COP00944736OtherMEDICARE RAILROAD CARRIER PTAN
COP00944736OtherMEDICARE RAILROAD CARRIER PTAN
COD43141Medicare UPIN
CO01367614Medicaid