1679668875 NPI number — DR. CARY K GOODMAN PH.D.

Table of content: DR. CARY K GOODMAN PH.D. (NPI 1679668875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679668875 NPI number — DR. CARY K GOODMAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
CARY
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1679668875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 SHERLEY PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-576-1371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2335 BLACK ROCK TPKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-334-7411
Provider Business Practice Location Address Fax Number:
203-372-7596
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2056 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060002056CT01 . This is a "ANTEHM BC BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 353667 . This is a "MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004250370 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com