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General NPI Number Information
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NPI Number | 1801882428
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Entity Type | Individual
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Provider Name | TERESA DUDEK GOODPASTER MD
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Gender | Female
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Dates
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Enumeration Date | 09/20/2005
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Last Update Date | 01/22/2010
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Provider Practice Location Address
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Address Line | 3051 6TH STREET
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City | MARIANNA
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State | FL
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Zip | 32446-1933
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Country | US
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Telephone | 850-482-0017
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Fax |
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Provider Business Mailing Address
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Address Line | 3051 6TH STREET
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City | MARIANNA
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State | FL
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Zip | 32446-1933
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Country | US
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Telephone | 850-482-0017
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 35-06-3092-D
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME98349
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License Number State | FL
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