Provider Demographics
NPI:1245457514
Name:GOODMAN, DIANA JEANNE (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:JEANNE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:49 SPRING ST
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-883-1414
Practice Address - Fax:207-883-1010
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP010252084N0400X
PAMD4398482084N0400X
SCMD 344402084N0400X
IL036.1348582084N0400X
MEMD208952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology