Provider Demographics
NPI:1831186337
Name:GOODMAN, MARK STEPHEN (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
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 1:2900 DAGGETT AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-7101
Mailing Address - Country:US
Mailing Address - Phone:541-884-1371
Mailing Address - Fax:541-882-3862
Practice Address - Street 1:2900 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-7101
Practice Address - Country:US
Practice Address - Phone:541-884-1371
Practice Address - Fax:541-882-3862
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD205022085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY191725Medicaid
OR150322Medicaid
OR100327Medicare ID - Type Unspecified
CAXPY191725Medicaid