Healthcare Provider Details

I. General information

NPI: 1164947248
Provider Name (Legal Business Name): COURTNEY GRACE GOODE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 FORESTVILLE PL
FORESTVILLE MD
20747-4409
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 301-420-6610
  • Fax: 301-735-0294
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002906
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2623
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: