=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659334852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VALERIE ELLEN GOODMAN DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2006
-----------------------------------------------------
Last Update Date | 09/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2540 CENTREVILLE RD
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21617-2681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-758-4432
-----------------------------------------------------
Fax | 410-758-1938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 FRONT AVENUE SUITE 300
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-296-7190
-----------------------------------------------------
Fax | 443-991-7768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H57821
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------