Provider Demographics
NPI:1588698468
Name:GOODMAN, ROBERT C (DPM PC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DPM PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COLONIAL RD STE 8
Mailing Address - Street 2:COLONIAL OFFICE PARK
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2947
Mailing Address - Country:US
Mailing Address - Phone:978-744-4904
Mailing Address - Fax:978-744-2589
Practice Address - Street 1:10 COLONIAL RD STE 8
Practice Address - Street 2:COLONIAL OFFICE PARK
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2947
Practice Address - Country:US
Practice Address - Phone:978-744-4904
Practice Address - Fax:978-744-2589
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1635213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0341363Medicaid
G0Y70685Medicare ID - Type Unspecified
T58720Medicare UPIN
R0Y77116Medicare ID - Type UnspecifiedGROUP