Healthcare Provider Details

I. General information

NPI: 1700877628
Provider Name (Legal Business Name): FRED L GOODMAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARINE CORPS AIR STATION, BUILDING 1175 BOX 99116
YUMA AZ
85369-9116
US

IV. Provider business mailing address

NAVAL HOSPITAL CAMP PENDLETON BUILDING H-100
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 928-269-6091
  • Fax:
Mailing address:
  • Phone: 928-269-6091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0074276
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: