Healthcare Provider Details

I. General information

NPI: 1053315036
Provider Name (Legal Business Name): TODD A GOODGLICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 WISCONSIN AVE STE 1209
CHEVY CHASE MD
20815-4301
US

IV. Provider business mailing address

5454 WISCONSIN AVE STE 950
CHEVY CHASE MD
20815-6912
US

V. Phone/Fax

Practice location:
  • Phone: 301-841-6595
  • Fax: 301-797-9454
Mailing address:
  • Phone: 301-657-5700
  • Fax: 301-654-9132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number0101043516
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberMD21176
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number0101043516
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberD0037803
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberMD21176
License Number StateDC
# 6
Primary TaxonomyY
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberD0037803
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101043516
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD21176
License Number StateDC
# 9
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0037803
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: