Provider Demographics
NPI:1083748966
Name:GOODRICH, SCOTT T (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:GOODRICH
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 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:855-963-2100
Mailing Address - Fax:239-236-2775
Practice Address - Street 1:2514 E DUPONT RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1619
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078092A207V00000X, 207VX0201X, 207VX0201X
MN758436207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology