Provider Demographics
NPI:1215925771
Name:GOODMAN, HARRIS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:HARRIS
Middle Name:MICHAEL
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 1:1541 FLORIDA AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4429
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:209-523-0764
Practice Address - Street 1:1541 FLORIDA AVE
Practice Address - Street 2:STE 200
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4429
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-523-0764
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19278208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD169ZOtherINDIVIDUAL PTAN - MEDICARE
CAZZZ48224ZOtherMEDICARE IDENTIFICATION #
CA020018719OtherRAILROAD MEDICARE
CACD069AOtherGROUP PTAN- MEDICARE
CAZZZ48224ZOtherMEDICARE IDENTIFICATION #