Provider Demographics
NPI:1154977965
Name:GOODMAN, DAVID (DPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W BUCKINGHAM PL APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2372
Mailing Address - Country:US
Mailing Address - Phone:847-732-5095
Mailing Address - Fax:
Practice Address - Street 1:939 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7138
Practice Address - Country:US
Practice Address - Phone:312-337-3673
Practice Address - Fax:312-337-4903
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.024399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist