Provider Demographics
NPI:1811964125
Name:GOODMAN, CLIFFORD L (OD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:L
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:615 N ANDOVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002
Practice Address - Country:US
Practice Address - Phone:316-733-4322
Practice Address - Fax:316-733-4322
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1068-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST43655Medicare UPIN
KS014708Medicare PIN