Provider Demographics
NPI:1043285596
Name:GOODMAN, DOUGLAS E (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8252
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64508-8252
Mailing Address - Country:US
Mailing Address - Phone:816-271-6575
Mailing Address - Fax:816-271-6139
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6575
Practice Address - Fax:816-271-6139
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6C872085R0202X
KS04329892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202192837Medicaid
MO35032011OtherBCBS KANSAS CITY MO
KS200334530AMedicaid
MOP00154639OtherRR MEDICARE GROUP CK7871
KS203405OtherBCBS KS FOR MO LOCATION
KS111294001Medicare PIN
MOA12412Medicare UPIN
MO202192837Medicaid