Healthcare Provider Details

I. General information

NPI: 1982666855
Provider Name (Legal Business Name): ROBERT LEE GOODMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 MEDICAL CENTER DR SUITE C
ROHNERT PARK CA
94928-2900
US

IV. Provider business mailing address

1331 MEDICAL CENTER DR SUITE C
ROHNERT PARK CA
94928-2900
US

V. Phone/Fax

Practice location:
  • Phone: 707-584-7474
  • Fax: 707-584-7495
Mailing address:
  • Phone: 707-584-7474
  • Fax: 707-584-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA26203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: