Healthcare Provider Details

I. General information

NPI: 1083610059
Provider Name (Legal Business Name): MARK GOODSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SAINT ANDREWS LN
GLEN COVE NY
11542-2254
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-7591
  • Fax:
Mailing address:
  • Phone: 516-945-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number194328
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: