Basic Information
| Provider Information | |||||||||
| NPI: | 1790353712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | VEGA | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S. EUCLID AVENUE | ||||||||
| Address2: | CAMPUS BOX 8111 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143623296 | ||||||||
| FaxNumber: | 3143629462 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BARNES JEW HOSP PLZ | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2021 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2021021950 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.