Healthcare Provider Details

I. General information

NPI: 1659378354
Provider Name (Legal Business Name): TONI B GOODYKOONTZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 JOHNSON AVE SUITE 4H
BRIDGEPORT WV
26330-1063
US

IV. Provider business mailing address

1400 JOHNSON AVE SUITE 4H
BRIDGEPORT WV
26330-1063
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-1990
  • Fax: 304-842-4471
Mailing address:
  • Phone: 304-842-1990
  • Fax: 304-842-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15898
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: