Provider Demographics
NPI:1285236661
Name:GOODMAN, BRUCE S I (BOCP)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
Last Name:GOODMAN
Suffix:I
Gender:M
Credentials:BOCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MIDDLE COUNTRY RD STE G
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2532
Mailing Address - Country:US
Mailing Address - Phone:631-732-5556
Mailing Address - Fax:631-732-0218
Practice Address - Street 1:280 MIDDLE COUNTRY RD STE G
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2532
Practice Address - Country:US
Practice Address - Phone:631-732-5556
Practice Address - Fax:631-732-0218
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00615045Medicaid