Provider Demographics
NPI:1144202482
Name:GOLTZ, HAYDEN R (DO)
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:R
Last Name:GOLTZ
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 1:1130 CROSSPOINTE LN
Mailing Address - Street 2:SUITE 8
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2986
Mailing Address - Country:US
Mailing Address - Phone:585-787-4407
Mailing Address - Fax:585-787-4428
Practice Address - Street 1:1130 CROSSPOINTE LN
Practice Address - Street 2:SUITE 8
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2986
Practice Address - Country:US
Practice Address - Phone:585-787-4407
Practice Address - Fax:585-787-4428
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02424546Medicaid
I01000Medicare UPIN
NY02424546Medicaid