Provider Demographics
NPI:1316906746
Name:GOODMAN, WARREN T (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:T
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-7580
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3448
Practice Address - Fax:651-254-3470
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-05-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN44982207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN319888000Medicaid