Healthcare Provider Details

I. General information

NPI: 1962426601
Provider Name (Legal Business Name): MICHAEL JASON GOLDSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE SUITE 404
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

20 PROSPECT AVE SUITE 404
HACKENSACK NJ
07601-1997
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2608
  • Fax: 551-996-0826
Mailing address:
  • Phone: 551-996-2608
  • Fax: 551-996-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number25MA09997500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number216102
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number216102
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02578334
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: