Healthcare Provider Details

I. General information

NPI: 1003892605
Provider Name (Legal Business Name): STEPHEN R GOLDBAS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 FORE RIVER PKWY STE 407
PORTLAND ME
04102-2780
US

IV. Provider business mailing address

195 FORE RIVER PKWY STE 470
PORTLAND ME
04102-2787
US

V. Phone/Fax

Practice location:
  • Phone: 207-749-6612
  • Fax: 207-747-4077
Mailing address:
  • Phone: 207-373-0770
  • Fax: 207-808-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1678
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1678
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: