Healthcare Provider Details

I. General information

NPI: 1023065539
Provider Name (Legal Business Name): JACK GOLDMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 2ND ST NE
AUBURN WA
98002-4902
US

IV. Provider business mailing address

33634 7TH PL SW
FEDERAL WAY WA
98023-5004
US

V. Phone/Fax

Practice location:
  • Phone: 253-833-3650
  • Fax:
Mailing address:
  • Phone: 253-833-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00017877
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00017877
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: