Provider Demographics
NPI:1013003615
Name:GOLDSTEIN, MICHAEL PHILIP (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILIP
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:396 CROMWELL AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1841
Mailing Address - Country:US
Mailing Address - Phone:860-529-4261
Mailing Address - Fax:860-721-7003
Practice Address - Street 1:396 CROMWELL AVE
Practice Address - Street 2:UNIT B
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1841
Practice Address - Country:US
Practice Address - Phone:860-529-4261
Practice Address - Fax:860-721-7003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-06-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT002545152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU86987Medicare PIN
CTU86987Medicare UPIN