Healthcare Provider Details

I. General information

NPI: 1659335636
Provider Name (Legal Business Name): MITCHELL ROBERT GOLDSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N EDDY ST
SOUTH BEND IN
46617-2920
US

IV. Provider business mailing address

107 N EDDY ST
SOUTH BEND IN
46617-2920
US

V. Phone/Fax

Practice location:
  • Phone: 574-246-1036
  • Fax: 574-246-1634
Mailing address:
  • Phone: 574-246-1036
  • Fax: 574-246-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01041575
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01041575
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: