Provider Demographics
NPI:1588916233
Name:GOODMAN, CASEY LEE (IDC)
Entity type:Individual
Prefix:MR
First Name:CASEY
Middle Name:LEE
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 FRY ST
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023-6502
Mailing Address - Country:US
Mailing Address - Phone:704-490-6885
Mailing Address - Fax:
Practice Address - Street 1:255 FRY ST
Practice Address - Street 2:
Practice Address - City:CHINA GROVE
Practice Address - State:NC
Practice Address - Zip Code:28023-6502
Practice Address - Country:US
Practice Address - Phone:704-490-6885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC228747831710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman