Provider Demographics
NPI:1770546012
Name:GOODMAN, PETER LEWIS (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:LEWIS
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 1:8220 MEADOWBRIDGE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2336
Mailing Address - Country:US
Mailing Address - Phone:804-559-0423
Mailing Address - Fax:804-559-1260
Practice Address - Street 1:8220 MEADOWBRIDGE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2336
Practice Address - Country:US
Practice Address - Phone:804-559-0423
Practice Address - Fax:804-559-1260
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101019253207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6022057Medicaid
VA6022057Medicaid
VAB09740Medicare UPIN