Provider Demographics
NPI:1114929858
Name:GOLDSTEIN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GOLDSTEIN
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 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:218C SUNSET RD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1104
Practice Address - Country:US
Practice Address - Phone:609-877-0400
Practice Address - Fax:609-877-1682
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03701800207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1998200Medicaid
NJ1018864OtherCIGNA
NJP3641368OtherOXFORD
NJ0090492000OtherAMERIHEALHT/KEYSTONE/ IBC
NJ3818454OtherAETNA
NJ183070OtherAMERIHEALTH PPO/PA BS
NJ21420OtherUNIVERISITY HEALTH PLAN
NJ3K6075OtherHEALTHNET, INC
NJ1346033OtherUNITED HEALTHCARE
NJ3K6075OtherHEALTHNET, INC
NJ21420OtherUNIVERISITY HEALTH PLAN
NJ183070AFJMedicare ID - Type Unspecified