Provider Demographics
NPI:1952383739
Name:GOODMARK, GARY VICTOR (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:VICTOR
Last Name:GOODMARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC01446111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ521437Medicare ID - Type UnspecifiedPROVIDER ID