Healthcare Provider Details

I. General information

NPI: 1043218159
Provider Name (Legal Business Name): GLEN K GOODMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 GRANDVIEW AVE
WATERBURY CT
06708-2514
US

IV. Provider business mailing address

87 GRANDVIEW AVE
WATERBURY CT
06708-2514
US

V. Phone/Fax

Practice location:
  • Phone: 203-574-2020
  • Fax:
Mailing address:
  • Phone: 203-574-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number46944
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number67111
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: