Provider Demographics
NPI:1013914910
Name:GOODRICH, ROBERT G (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
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 1:2704 SAINT JUDE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3670
Mailing Address - Country:US
Mailing Address - Phone:336-954-7546
Mailing Address - Fax:336-235-4018
Practice Address - Street 1:2704 SAINT JUDE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3670
Practice Address - Country:US
Practice Address - Phone:336-954-7546
Practice Address - Fax:336-235-4018
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001142207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134YUMedicaid
NC89134YUMedicaid
NCH84573Medicare UPIN