Healthcare Provider Details

I. General information

NPI: 1396819165
Provider Name (Legal Business Name): REBECCA A GOEDEKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 COPPERMINE RD
WOODSBORO MD
21798-8319
US

IV. Provider business mailing address

10200 COPPERMINE RD
WOODSBORO MD
21798-8319
US

V. Phone/Fax

Practice location:
  • Phone: 301-845-6322
  • Fax: 240-578-4480
Mailing address:
  • Phone: 301-845-6322
  • Fax: 240-578-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0040223
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: