Provider Demographics
NPI:1912989765
Name:GARY GOODMARK DC PA
Entity Type:Organization
Organization Name:GARY GOODMARK DC PA
Other - Org Name:DR. GARY GOODMARK
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:GOODMARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-891-4121
Mailing Address - Street 1:615 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1357
Mailing Address - Country:US
Mailing Address - Phone:201-891-4121
Mailing Address - Fax:201-891-6489
Practice Address - Street 1:615 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1357
Practice Address - Country:US
Practice Address - Phone:201-891-4121
Practice Address - Fax:201-891-6489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
521437Medicare PIN