Healthcare Provider Details

I. General information

NPI: 1770014102
Provider Name (Legal Business Name): ALYSSA GLORIA GOODMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE MEDICAL STAFF SERVICES MLC 2008
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-6796
  • Fax: 513-636-7967
Mailing address:
  • Phone: 212-305-2995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.141273
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number305424
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: