1679532287 NPI number — DR. JONATHAN EDWARD GOLDSTEIN M.D.

Table of content: DR. JONATHAN EDWARD GOLDSTEIN M.D. (NPI 1679532287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679532287 NPI number — DR. JONATHAN EDWARD GOLDSTEIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSTEIN
Provider First Name:
JONATHAN
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1679532287
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
769 NORTHFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
WEST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07052-1198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-731-9442
Provider Business Mailing Address Fax Number:
973-731-2918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
268 MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07102-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-877-5463
Provider Business Practice Location Address Fax Number:
973-877-2567
Provider Enumeration Date:
03/22/2006

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: 174400000X , with the licence number:  MA39764 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 68488 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1512404 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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