Basic Information
| Provider Information | |||||||||
| NPI: | 1609018860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | QUINCY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 NE CUSHING DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419081217 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1253 NW CANAL BLVD | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415488131 | ||||||||
| FaxNumber: | 5415266608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD160709 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PS0010X | MD160709 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 207PE0004X | MD160709 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 1609018860 | 01 | NPI | OTHER |