Provider Demographics
NPI:1184773517
Name:GOODMAN, CHARLES BARRY (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BARRY
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5898
Mailing Address - Country:US
Mailing Address - Phone:805-495-2735
Mailing Address - Fax:805-495-7406
Practice Address - Street 1:425 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5898
Practice Address - Country:US
Practice Address - Phone:805-495-2735
Practice Address - Fax:805-495-7406
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0171580OtherBLUE SHIELD
CAU05569Medicare UPIN