Provider Demographics
NPI:1053315036
Name:GOODGLICK, TODD A (MD)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:A
Last Name:GOODGLICK
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 1:5454 WISCONSIN AVE STE 950
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-6912
Mailing Address - Country:US
Mailing Address - Phone:301-657-5700
Mailing Address - Fax:301-654-9132
Practice Address - Street 1:5530 WISCONSIN AVE STE 1209
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4301
Practice Address - Country:US
Practice Address - Phone:301-841-6595
Practice Address - Fax:301-797-9454
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043516207WX0200X, 207WX0109X, 207W00000X
DCMD21176207WX0109X, 207WX0200X, 207W00000X
MDD0037803207WX0200X, 207WX0109X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD355041900Medicaid
DC022589600Medicaid
G0012047W78Medicare PIN
A93339Medicare UPIN