Provider Demographics
NPI:1366870479
Name:GOODMAN EYE CLINIC
Entity type:Organization
Organization Name:GOODMAN EYE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMOTRIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-698-3680
Mailing Address - Street 1:10513 SILVERDALE WAY NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9499
Mailing Address - Country:US
Mailing Address - Phone:360-698-3680
Mailing Address - Fax:360-692-2963
Practice Address - Street 1:10513 SILVERDALE WAY NW
Practice Address - Street 2:SUITE 110
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9499
Practice Address - Country:US
Practice Address - Phone:360-698-3680
Practice Address - Fax:360-692-2963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1749TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1015164Medicaid
WA1015164Medicaid
WAG8856486Medicare PIN