Healthcare Provider Details

I. General information

NPI: 1265545974
Provider Name (Legal Business Name): GARY L GOLDFADEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 HOLLYWOOD BLVD SUITE 205
HOLLYWOOD FL
33021-6750
US

IV. Provider business mailing address

3816 HOLLYWOOD BLVD SUITE 205
HOLLYWOOD FL
33021-6750
US

V. Phone/Fax

Practice location:
  • Phone: 954-966-5409
  • Fax: 954-966-0852
Mailing address:
  • Phone: 954-966-5409
  • Fax: 954-966-0852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME13631
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME13631
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: