Provider Demographics
NPI:1962827162
Name:GOODMAN, SARAH I
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:GOODMAN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 3RD AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6943
Mailing Address - Country:US
Mailing Address - Phone:718-757-9912
Mailing Address - Fax:
Practice Address - Street 1:633 3RD AVE FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6943
Practice Address - Country:US
Practice Address - Phone:718-757-9912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2942742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05244899Medicaid