Basic Information
| Provider Information | |||||||||
| NPI: | 1245396316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3406 COLLEGE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098132332 | ||||||||
| FaxNumber: | 4092320559 | ||||||||
| Practice Location | |||||||||
| Address1: | 3406 COLLEGE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098131677 | ||||||||
| FaxNumber: | 4098131699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2006 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | P8670 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | 084167 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | P8670 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 4102617 | 01 | FL | AETNA | OTHER | 26082 | 01 | FL | BCBS OF FLORIDA | OTHER | 006284200 | 05 | FL | MEDICAID | 6113905 | 01 | FL | CIGNA | OTHER | 1178003 | 01 | FL | UNITED HEALTHCARE | OTHER |