Provider Demographics
NPI:1013960442
Name:GOODMAN, RAYMOND C JR (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:C
Last Name:GOODMAN
Suffix:JR
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 1:5401 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3219
Mailing Address - Country:US
Mailing Address - Phone:479-314-4757
Mailing Address - Fax:479-314-4704
Practice Address - Street 1:7001 ROGERS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4073
Practice Address - Country:US
Practice Address - Phone:479-314-4620
Practice Address - Fax:479-314-4629
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4716174400000X
ARC-4716208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100082220AOtherOK MEDICAID
AR105795001Medicaid
AR51933OtherAR BLUECROSS BLUESHIELD
AR51933OtherAR BLUECROSS BLUESHIELD
ARD79448Medicare UPIN