Healthcare Provider Details

I. General information

NPI: 1679556633
Provider Name (Legal Business Name): MATTHEW MORTENSEN GOODMAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 NEWPORT CENTER DR STE 158
NEWPORT BEACH CA
92660-0934
US

IV. Provider business mailing address

13261 CROMWELL DR
TUSTIN CA
92780-4705
US

V. Phone/Fax

Practice location:
  • Phone: 949-719-1800
  • Fax: 949-719-1810
Mailing address:
  • Phone: 714-955-1214
  • Fax: 623-259-6754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG53769
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG53769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: