Provider Demographics
NPI:1770553877
Name:GOODMAN, JERRY CLAY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:CLAY
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:PO BOX 4698
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3411
Practice Address - Country:US
Practice Address - Phone:713-481-3544
Practice Address - Fax:713-432-0221
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4357207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132441010Medicaid
TX132441001Medicaid
TX132441011OtherCSHCN
TX81P707Medicare PIN
TX8G3113Medicare PIN
TXE35378Medicare UPIN
TX132441010Medicaid