Provider Demographics
NPI:1316098866
Name:GOODMAN, SUZAN R (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:SUZAN
Middle Name:R
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MARINE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOSS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:94038-9641
Mailing Address - Country:US
Mailing Address - Phone:650-563-7107
Mailing Address - Fax:
Practice Address - Street 1:600 MARINE BLVD
Practice Address - Street 2:
Practice Address - City:MOSS BEACH
Practice Address - State:CA
Practice Address - Zip Code:94038-9641
Practice Address - Country:US
Practice Address - Phone:650-563-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG082282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G822820Medicaid
CA00G822820Medicaid
CA00G822820Medicare ID - Type Unspecified