Provider Demographics
NPI:1114006103
Name:GOLDSMITH, MARK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:GOLDSMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 CHINKAPIN WAY
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-4523
Mailing Address - Country:US
Mailing Address - Phone:614-890-7300
Mailing Address - Fax:
Practice Address - Street 1:262 CHINKAPIN WAY
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-4523
Practice Address - Country:US
Practice Address - Phone:614-890-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH038474174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0284320Medicaid
OH038474OtherMEDICAL LICENSE
OH31-0993335-01OtherWC-GP
OH3109933350226OtherCARESOURCE
OH000000117883OtherANTHEM
OHNONEOtherNONE
OHBG3270333OtherDEA (BND)
OH3109933350226OtherCARESOURCE
OHCO2566Medicare UPIN