MEDICARE: JERRY CLAY GOODMAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	E4357	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	132441011	OTHER	TX	CSHCN

General Provider Information

NPI Number	:	1770553877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY CLAY GOODMAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 4698
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4698
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 BAYLOR PLZ
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-3411
Country	:	US
Telephone Number	:	713-481-3544
Fax Number	:	713-432-0221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	03/19/2009

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