Provider Demographics
NPI:1831235498
Name:GOODMAN, TERRY L (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:9501 TAYLORSVILLE RD STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2752
Practice Address - Country:US
Practice Address - Phone:502-499-2020
Practice Address - Fax:502-499-6747
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1071DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00106428OtherRR MEDICARE
KY77010718Medicaid
KY77010718Medicaid
00985002Medicare PIN