Provider Demographics
NPI:1194799874
Name:GOODMAN, BENJAMIN MITCHELL (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MITCHELL
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 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-8920
Mailing Address - Fax:757-446-5242
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 445
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-8920
Practice Address - Fax:757-446-5242
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234707208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA-028OtherTRICARE/CHAMPUS
VA72937OtherSENTARA OPTIMA
VAPAROtherAETNA
VA010001846Medicaid
VAPAROtherVIRGINIA PREMIER HEALTH
NC89066J8Medicaid
VAPAROtherFIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY
VA010001811Medicaid
VA466415OtherANTHEM
VAPAROtherCORVEL/CORCARE
NC066J8OtherBC/BS
VAPAROtherCIGNA
VA466414OtherANTHEM
VA2115045OtherUHC/MAMSI
VAPAROtherVIRGINIA HEALTH NETWORK
VAPAROtherUSA MANAGED CARE
VAPAROtherVIRGINIA HEALTH NETWORK
VA466415OtherANTHEM
VAP00100295Medicare PIN