Provider Demographics
NPI:1720169709
Name:GOODMAN, DENNIS STEPHEN (DO)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:STEPHEN
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:573-341-5300
Practice Address - Street 1:715 ST RT CC
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-308-7386
Practice Address - Fax:573-341-5300
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORSB71207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO080052033OtherRAILROAD MEDICARE
MO241605948Medicaid
MO080052033OtherRAILROAD MEDICARE
MO241605948Medicaid