Provider Demographics
NPI:1982669024
Name:GOODMAN, GARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1030 HARRINGTON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2967
Mailing Address - Country:US
Mailing Address - Phone:586-493-9229
Mailing Address - Fax:586-493-4396
Practice Address - Street 1:22250 PROVIDENCE DR STE 606
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6214
Practice Address - Country:US
Practice Address - Phone:248-443-1281
Practice Address - Fax:248-443-1411
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2019-08-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301044225208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10 3282495Medicaid
OM29150 003Medicare ID - Type Unspecified