Basic Information
| Provider Information | |||||||||
| NPI: | 1396731352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 AINSWORTH DR | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863051667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287781971 | ||||||||
| FaxNumber: | 9287710638 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 AINSWORTH DR | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863051667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287781971 | ||||||||
| FaxNumber: | 9287710638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 15335 | AZ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 272443 | 05 | AZ | MEDICAID |