Provider Demographics
NPI:1447275110
Name:GOODMAN, JASON ELLIOTT (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ELLIOTT
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 1:7602 BELAIR ROAD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236
Mailing Address - Country:US
Mailing Address - Phone:410-663-8100
Mailing Address - Fax:410-663-8119
Practice Address - Street 1:7602 BELAIR ROAD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236
Practice Address - Country:US
Practice Address - Phone:410-663-8100
Practice Address - Fax:410-663-8119
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD55846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4134320-00Medicaid
MD613816-01OtherBLUE CROSS/BLUE SHIELD
MD4134320-00Medicaid
MDS036Medicare PIN