1982639803 NPI number — DAVID WAYNE GOODMAN PHD

Table of content: DAVID WAYNE GOODMAN PHD (NPI 1982639803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982639803 NPI number — DAVID WAYNE GOODMAN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
DAVID
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

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:
1982639803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2639 SUNSET AVENUE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ROCKY MOUNT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27804-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-937-4455
Provider Business Mailing Address Fax Number:
252-937-3060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2639 SUNSET AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ROCKY MOUNT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27804-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-937-4455
Provider Business Practice Location Address Fax Number:
252-937-3060
Provider Enumeration Date:
07/11/2006

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: 103TC1900X , with the licence number:  0852 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC1900X , with the licence number: 072002957 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 03624 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6000021 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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