Healthcare Provider Details

I. General information

NPI: 1396430229
Provider Name (Legal Business Name): JACK GOLDSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-9880
  • Fax: 952-835-9880
Mailing address:
  • Phone: 952-835-9880
  • Fax: 952-835-4403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number82048
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: