1912989765 NPI number — GARY GOODMARK DC PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912989765 NPI number — GARY GOODMARK DC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY GOODMARK DC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912989765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 WYCKOFF AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYCKOFF
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07481-1357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-891-4121
Provider Business Mailing Address Fax Number:
201-891-6489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 WYCKOFF AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYCKOFF
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07481-1357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-891-4121
Provider Business Practice Location Address Fax Number:
201-891-6489
Provider Enumeration Date:
11/17/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOODMARK
Authorized Official First Name:
GARY
Authorized Official Middle Name:
VICTOR
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
201-891-4121

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)