Healthcare Provider Details

I. General information

NPI: 1578797866
Provider Name (Legal Business Name): MARK WILLIAM GOLDSCHMIDT IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 9, SCHOFIELD BARRACKS
SCHOFIELD BARRACKS HI
96857
US

IV. Provider business mailing address

94-515 MEHAME PL
WAIPAHU HI
96797-5813
US

V. Phone/Fax

Practice location:
  • Phone: 808-655-3117
  • Fax:
Mailing address:
  • Phone: 619-392-3314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: