Provider Demographics
NPI:1912106469
Name:GOODMAN, ANNETTE (DO)
Entity type:Individual
Prefix:DR
First Name:ANNETTE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 4TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3736
Mailing Address - Country:US
Mailing Address - Phone:423-613-6379
Mailing Address - Fax:423-613-6380
Practice Address - Street 1:434 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3736
Practice Address - Country:US
Practice Address - Phone:423-613-6379
Practice Address - Fax:423-613-6380
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO56972084N0400X
MEDO21092084N0400X
FLOS179732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110944400Medicaid
ME1912106469Medicaid