Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | G19278 | CA |
Y | 208600000X | Surgeon | G19278 | CA |
N | 2086S0127X | Trauma Surgeon | G19278 | CA |
NPI | 1215925771 |
---|---|
Provider Name | Harris Michael Goodman |
First Address | Modesto, CA 95350-4429 |
Second Address | Modesto, CA 95350-4429 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2005 |
Last Update Date | 29/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
020018719 | RAILROAD MEDICARE (01) | CA |
A40585 | (02) | CA |
CD069A | GROUP PTAN- MEDICARE (01) | CA |
CD169Z | INDIVIDUAL PTAN - MEDICARE (01) | CA |
ZZZ48224Z | MEDICARE IDENTIFICATION # (01) | CA |