Provider Demographics
NPI:1285686469
Name:GOODRICK, GABRIELLE (MD)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:GOODRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4141 N 32ND STREET
Mailing Address - Street 2:STE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4775
Mailing Address - Country:US
Mailing Address - Phone:602-279-2337
Mailing Address - Fax:602-448-8321
Practice Address - Street 1:4141 N 32ND STREET
Practice Address - Street 2:STE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-4775
Practice Address - Country:US
Practice Address - Phone:602-279-2337
Practice Address - Fax:602-448-8321
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ22811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0836190OtherBCBS
AZ86-0937180OtherTAX ID #
AZ0899222OtherAETNA
AZ815204OtherHUMANA
AZ86-0937180OtherTAX ID #
AZG27379Medicare UPIN