Provider Demographics
NPI:1245325968
Name:GOODRICH, DEBORA ANN (DO)
Entity type:Individual
Prefix:MRS
First Name:DEBORA
Middle Name:ANN
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WELL BROOK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3873
Mailing Address - Country:US
Mailing Address - Phone:770-922-3023
Mailing Address - Fax:770-929-1016
Practice Address - Street 1:1301 WELL BROOK CIRCLE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3873
Practice Address - Country:US
Practice Address - Phone:770-922-3023
Practice Address - Fax:770-929-1016
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00691094AMedicaid
G21655Medicare UPIN
GA00691094AMedicaid