Basic Information
| Provider Information | |||||||||
| NPI: | 1679556633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MORTENSEN | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 E 17TH STREET | ||||||||
| Address2: | STE W-248 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145475151 | ||||||||
| FaxNumber: | 7145474027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 E 17TH STREET | ||||||||
| Address2: | STE W-248 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145475151 | ||||||||
| FaxNumber: | 7145474027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 12/23/2008 | ||||||||
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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 | 207N00000X | G53769 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00G537690 | 05 | CA | MEDICAID |