Basic Information
Provider Information | |||||||||
NPI: | 1811976046 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODLETT | ||||||||
FirstName: | ALLISON | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1460 | ||||||||
Address2: |   | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 224021460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407862100 | ||||||||
FaxNumber: | 5407860677 | ||||||||
Practice Location | |||||||||
Address1: | 4701 SPOTSYLVANIA PARKWAY | ||||||||
Address2: | SUITE 200 | ||||||||
City: | FREDERICKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 22408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5408345430 | ||||||||
FaxNumber: | 5408345431 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2006 | ||||||||
LastUpdateDate: | 03/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101238185 | VA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 3867087 | 01 | VA | AETNA HMO | OTHER | CO2375 | 01 | VA | MEDICARE GROUP | OTHER | 8133244 | 01 | VA | MAMSI | OTHER | 0101238185 | 01 | VA | LICENSE | OTHER | 010165237 | 05 | VA |   | MEDICAID | 7130390 | 01 | VA | AETNA NON HMO | OTHER | CA9037 | 01 | VA | MCR RAILROAD GROUP | OTHER | 000502782 | 01 | VA | AETNA CAP | OTHER | 179657 | 01 | VA | ANTHEM | OTHER |