Healthcare Provider Details

I. General information

NPI: 1124449442
Provider Name (Legal Business Name): JOHN ETHAN GOODRICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 X ST
SACRAMENTO CA
95817-2200
US

IV. Provider business mailing address

2215 ROSE ST
BERKELEY CA
94709-1430
US

V. Phone/Fax

Practice location:
  • Phone: 916-816-0478
  • Fax:
Mailing address:
  • Phone: 424-366-3794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA149423
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-17073
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA149423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: