Healthcare Provider Details

I. General information

NPI: 1639235765
Provider Name (Legal Business Name): KEITH GOLDSTEIN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4649 GARDENS PARK BLVD APT 3308
ORLANDO FL
32839-2623
US

IV. Provider business mailing address

4649 GARDENS PARK BLVD APT 3308
ORLANDO FL
32839-2623
US

V. Phone/Fax

Practice location:
  • Phone: 407-509-8852
  • Fax:
Mailing address:
  • Phone: 407-509-8852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: