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General NPI Number Information
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NPI Number | 1245233261
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Entity Type | Individual
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Provider Name | JACK D GOLDSTEIN M.D.1208
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Gender | Male
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Dates
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Enumeration Date | 05/23/2005
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Last Update Date | 11/02/2009
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Provider Practice Location Address
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Address Line | 400 MASSASOIT AVE SUITE 201
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City | E PROVIDENCE
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State | RI
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Zip | 02914-2012
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Country | US
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Telephone | 401-919-5222
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Fax | 401-919-5227
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Provider Business Mailing Address
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Address Line | 400 MASSASOIT AVE SUITE 201
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City | E PROVIDENCE
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State | RI
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Zip | 02914-2012
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Country | US
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Telephone | 401-919-5222
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Fax | 401-919-5227
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | RI8073
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License Number State | RI
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