Provider Demographics
NPI:1033171673
Name:GOLDSHLACK, PAUL (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GOLDSHLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-2111
Mailing Address - Country:US
Mailing Address - Phone:517-482-2020
Mailing Address - Fax:517-482-3664
Practice Address - Street 1:1433 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2111
Practice Address - Country:US
Practice Address - Phone:517-482-2020
Practice Address - Fax:517-482-3664
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPG007284207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1545390Medicaid
B45906Medicare UPIN
MI1545390Medicaid
ON86990001Medicare ID - Type Unspecified