Healthcare Provider Details

I. General information

NPI: 1629005780
Provider Name (Legal Business Name): MARK GOODMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 LONG BEACH BLVD
LONG BEACH CA
90807-5062
US

IV. Provider business mailing address

2360 PACIFIC AVE
LONG BEACH CA
90806-3051
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-2000
  • Fax: 562-494-7792
Mailing address:
  • Phone: 562-981-6856
  • Fax: 562-426-7792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA31080
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: