Basic Information
| Provider Information | |||||||||
| NPI: | 1174500631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575944006 | ||||||||
| FaxNumber: | 7575942195 | ||||||||
| Practice Location | |||||||||
| Address1: | 4032 CAMPBELL RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236024252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578773956 | ||||||||
| FaxNumber: | 7578567121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000165 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1174500631 | 05 | VA | MEDICAID |