MEDICARE: DR. MICHELINE GOULART M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	315500	NY

General Provider Information

NPI Number	:	1568840940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELINE GOULART M.D.

Provider Business Mailing Address
First Line	:	800 NORTHERN BLVD STE 6
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11021-5314
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045 NORTHERN BLVD FL 2
Second Line	:
City	:	ROSLYN
State	:	NY
Zip	:	11576-1502
Country	:	US
Telephone Number	:	516-279-2616
Fax Number	:	516-279-2632

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2015
Last Update Date	:	06/13/2023

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