Provider Demographics
NPI:1700805124
Name:GOODMAN, PAUL M (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
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 1:4033 3RD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2117
Mailing Address - Country:US
Mailing Address - Phone:619-294-2350
Mailing Address - Fax:619-296-5719
Practice Address - Street 1:4033 3RD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2117
Practice Address - Country:US
Practice Address - Phone:619-294-2350
Practice Address - Fax:619-296-5719
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24856207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G248561Medicaid
CAG24856Medicare ID - Type Unspecified
A42421Medicare UPIN