Provider Demographics
NPI:1457334799
Name:GOODMAN, BRENT P (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:P
Last Name:GOODMAN
Suffix:
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 1:3535 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3635
Mailing Address - Country:US
Mailing Address - Phone:385-430-1430
Mailing Address - Fax:
Practice Address - Street 1:3535 S MARKET ST
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3635
Practice Address - Country:US
Practice Address - Phone:385-430-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN432952084N0400X
AZ291082084N0400X
UT13725843-12052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259A980OtherTRIWEST
AZP00178432OtherRAILROAD MEDICARE
AZ872920Medicaid
AZP00178432OtherRAILROAD MEDICARE
MN130001427Medicare PIN
AZ872920Medicaid