Provider Demographics
NPI:1164654729
Name:JACK GOODMAN, M.D. PC
Entity type:Organization
Organization Name:JACK GOODMAN, M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-454-0415
Mailing Address - Street 1:9 LIVINGSTON ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-4719
Mailing Address - Country:US
Mailing Address - Phone:845-454-0415
Mailing Address - Fax:845-454-0914
Practice Address - Street 1:9 LIVINGSTON ST
Practice Address - Street 2:SUITE 9
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4719
Practice Address - Country:US
Practice Address - Phone:845-454-0415
Practice Address - Fax:845-454-0914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty