Basic Information
| Provider Information | |||||||||
| NPI: | 1881626315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODEN | ||||||||
| FirstName: | EARL ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 260 | ||||||||
| Address2: | 21 LONGMEADOW ROAD | ||||||||
| City: | WESTBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015810260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088983789 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27 PARK ST | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026015230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088625000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 81063 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3201350 | 05 | MA | MEDICAID | 797922 | 01 | MA | TUFTS | OTHER | J21114 | 01 | MA | BLUE SHIELD | OTHER | 15-00698 | 01 | MA | EVERCARE | OTHER |