Provider Demographics
NPI:1700877628
Name:GOODMAN, FRED L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:L
Last Name:GOODMAN
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:NAVAL HOSPITAL CAMP PENDLETON
Mailing Address - Street 2:BUILDING H-100
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5191
Mailing Address - Country:US
Mailing Address - Phone:928-269-6091
Mailing Address - Fax:
Practice Address - Street 1:MARINE CORPS AIR STATION, BUILDING 1175
Practice Address - Street 2:BOX 99116
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85369-9116
Practice Address - Country:US
Practice Address - Phone:928-269-6091
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0074276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0074276OtherMEDICAL LICENSE