Healthcare Provider Details

I. General information

NPI: 1639924327
Provider Name (Legal Business Name): MARK SPENCER GOODMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 LORAIN AVE
CLEVELAND OH
44113-3707
US

IV. Provider business mailing address

13093 CEDAR RD
CLEVELAND OH
44118-2709
US

V. Phone/Fax

Practice location:
  • Phone: 765-251-3466
  • Fax:
Mailing address:
  • Phone: 765-251-3466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.027571
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: