Provider Demographics
NPI:1992782411
Name:GOODMAN, THERESA B (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:B
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:B
Other - Last Name:MCFALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PSC 80, BOX 21521
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:315-630-4229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230488207Q00000X, 2083X0100X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine