Provider Demographics
NPI:1962157503
Name:GOODMAN, JUSTIN BLAKE (RD, LDN)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:BLAKE
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9232 RAVENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3425
Mailing Address - Country:US
Mailing Address - Phone:443-803-2381
Mailing Address - Fax:
Practice Address - Street 1:1301 YORK RD STE 800
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6011
Practice Address - Country:US
Practice Address - Phone:410-686-0459
Practice Address - Fax:425-242-3401
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered