Provider Demographics
NPI:1871973313
Name:GOODENOUGH, ELLIOT (MD, PHD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:GOODENOUGH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 VINE ST FL 4
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1031
Mailing Address - Country:US
Mailing Address - Phone:215-762-2530
Mailing Address - Fax:215-762-2531
Practice Address - Street 1:1427 VINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1031
Practice Address - Country:US
Practice Address - Phone:215-762-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-30
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460791207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103315777Medicaid