Provider Demographics
NPI:1689828253
Name:GOODSPEED, DAVID R (C PED)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:GOODSPEED
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4542
Mailing Address - Country:US
Mailing Address - Phone:802-773-1543
Mailing Address - Fax:
Practice Address - Street 1:106 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4542
Practice Address - Country:US
Practice Address - Phone:802-773-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT20215273225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006112Medicaid
VT1016140001OtherNGS SUPPLIER
VT1006112Medicaid