Healthcare Provider Details

I. General information

NPI: 1962157503
Provider Name (Legal Business Name): JUSTIN BLAKE GOODMAN RD, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 YORK RD STE 800
TIMONIUM MD
21093-6011
US

IV. Provider business mailing address

9232 RAVENWOOD RD
ROSEDALE MD
21237-3425
US

V. Phone/Fax

Practice location:
  • Phone: 410-686-0459
  • Fax: 425-242-3401
Mailing address:
  • Phone: 443-803-2381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: