Provider Demographics
NPI:1265428353
Name:GOODMAN, ROY CHARLES JR (OD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:CHARLES
Last Name:GOODMAN
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1110 EASTDALE MALL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-2118
Mailing Address - Country:US
Mailing Address - Phone:334-272-4722
Mailing Address - Fax:334-272-5096
Practice Address - Street 1:1110 EASTDALE MALL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-2118
Practice Address - Country:US
Practice Address - Phone:334-272-4722
Practice Address - Fax:334-272-5096
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS729-TA155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL143416Medicaid
AL000058324Medicare PIN
AL143416Medicaid