Provider Demographics
NPI:1053529578
Name:GOODRICH, ROBERT CLAIRE (US NAVY IDC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLAIRE
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:US NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12937 CREE CT
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3829
Mailing Address - Country:US
Mailing Address - Phone:858-748-5114
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5291
Practice Address - Country:US
Practice Address - Phone:619-532-5212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman