1962638775 NPI number — ROY GOODMAN, D.C., P.A.

Table of content: (NPI 1962638775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962638775 NPI number — ROY GOODMAN, D.C., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROY GOODMAN, D.C., P.A.
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:
1962638775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMPANO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33061-6303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-599-6273
Provider Business Mailing Address Fax Number:
954-783-1007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 W. SAMPLE ROAD
Provider Second Line Business Practice Location Address:
BLDG. 2, SUITE 9A
Provider Business Practice Location Address City Name:
DEERFIELD BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-599-6273
Provider Business Practice Location Address Fax Number:
954-783-1007
Provider Enumeration Date:
06/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
ROY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-599-6273

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH7965 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 53979 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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