Basic Information
| Provider Information | |||||||||
| NPI: | 1962420968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3816 WOODBINE ST | ||||||||
| Address2: | |||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208154957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016572355 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984483 | ||||||||
| FaxNumber: | 7035730880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/22/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/04/2012 | ||||||||
| NPIReactivationDate: | 04/15/2013 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 0101023891 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 0101023891 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 0101023891 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 0101023891 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 0101023891 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 0101023891 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | 0101023891 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 0002 | 01 | VA | CAREFIRST BCBS | OTHER |