Provider Demographics
NPI:1912292657
Name:GOEDJEN, BRENT THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:GOEDJEN
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 1:135 NORCROSS ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3867
Mailing Address - Country:US
Mailing Address - Phone:256-320-9746
Mailing Address - Fax:262-203-9631
Practice Address - Street 1:135 NORCROSS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3867
Practice Address - Country:US
Practice Address - Phone:678-870-2020
Practice Address - Fax:262-203-9631
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME114104207N00000X
GA73450207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009270000Medicaid
FL009270000Medicaid