Provider Demographics
NPI:1619212149
Name:GOODMAN, ELI NATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:ELI
Middle Name:NATHAN
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 NORTHSIDE HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2825
Mailing Address - Country:US
Mailing Address - Phone:540-561-6615
Mailing Address - Fax:
Practice Address - Street 1:6600 NORTHSIDE HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2825
Practice Address - Country:US
Practice Address - Phone:540-561-6615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117798207ZP0102X
VA0101255858207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology