Basic Information
| Provider Information | |||||||||
| NPI: | 1932498482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5711 SARVIS AVE | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207371394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012774844 | ||||||||
| FaxNumber: | 3019273221 | ||||||||
| Practice Location | |||||||||
| Address1: | 5711 SARVIS AVE | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207371394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012774844 | ||||||||
| FaxNumber: | 3019273221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 07/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | D79841 | MD | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | D79841 | 01 | MD | MEDICAL LICENSE | OTHER |