Basic Information
| Provider Information | |||||||||
| NPI: | 1023376738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | CLARKE | ||||||||
| MiddleName: | WORLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2409 MCCALL RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787033025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062363144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 ROUND ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786814004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123411000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA09703200 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | R1033 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.