Provider Demographics
NPI:1801882428
Name:GOODPASTER, TERESA DUDEK (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:DUDEK
Last Name:GOODPASTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:ANN
Other - Last Name:DUDEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3051 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1933
Mailing Address - Country:US
Mailing Address - Phone:850-482-0017
Mailing Address - Fax:
Practice Address - Street 1:3051 6TH STREET
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-1933
Practice Address - Country:US
Practice Address - Phone:850-482-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-3092-D208600000X
FLME98349208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279095500Medicaid
FL279095500Medicaid