1194749804 NPI number — JOHN M GOLD MD

Table of content: JOHN M GOLD MD (NPI 1194749804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194749804 NPI number — JOHN M GOLD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLD
Provider First Name:
JOHN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194749804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
319 S MANNING BLVD STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12208-1743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-438-0507
Provider Business Mailing Address Fax Number:
518-438-0981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARATOGA SPRINGS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12866-6049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-583-0111
Provider Business Practice Location Address Fax Number:
518-583-2426
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  122833 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10000778 . This is a "CDP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4145855 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000434084003 . This is a "BLUE SHIELD OF NORTHEASTE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 105151 . This is a "GHI HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7846749 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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