Basic Information
| Provider Information | |||||||||
| NPI: | 1790002004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 COUNTY ROAD 236 | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458408738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194271984 | ||||||||
| FaxNumber: | 4194273020 | ||||||||
| Practice Location | |||||||||
| Address1: | 7595 COUNTY ROAD 236 | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458408738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194271984 | ||||||||
| FaxNumber: | 4194272864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 36.003646 | OH | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | 36003646 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 0085763 | 05 | OH | MEDICAID |