Healthcare Provider Details

I. General information

NPI: 1811999485
Provider Name (Legal Business Name): GARY M GOODMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

456 N NEW BALLAS RD STE 129
SAINT LOUIS MO
63141-6812
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2694
  • Fax: 314-454-2515
Mailing address:
  • Phone: 314-569-1881
  • Fax: 314-569-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number102527
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number102527
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: