Healthcare Provider Details

I. General information

NPI: 1881602316
Provider Name (Legal Business Name): JONATHAN G GOLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SERVICE RD # A110
EAST LANSING MI
48824-7015
US

IV. Provider business mailing address

804 SERVICE RD # A201
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-3003
  • Fax: 517-353-5514
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301077191
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: