Provider Demographics
NPI:1861192924
Name:GOODMAN, MAX JUSTIN (MD/MS)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:JUSTIN
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD/MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N INGALLS ST BLDG NI4C06
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-0400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:734-615-2687
Practice Address - Street 1:300 N INGALLS ST BLDG NI4C06
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-0400
Practice Address - Country:US
Practice Address - Phone:734-615-2690
Practice Address - Fax:734-615-2687
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351052432APP24207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherMEDICAL STUDENT