Provider Demographics
NPI:1164574760
Name:GOLDSTEIN, JONATHAN VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:VICTOR
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 1:77 N CENTRE AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3923
Mailing Address - Country:US
Mailing Address - Phone:516-264-5900
Mailing Address - Fax:516-594-9728
Practice Address - Street 1:77 N CENTRE AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3923
Practice Address - Country:US
Practice Address - Phone:516-264-5900
Practice Address - Fax:516-594-9728
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092410208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
010092410NY01OtherANTHEM
4266128OtherAETNA
97942OtherUSHC
23614POtherGHI
NY00149028Medicaid
A5398OtherOXFORD
020015785OtherRAILROAD MEDICARE
0457009011OtherCIGNA
OC3104OtherHEALTHNET
OC3104OtherPHS
522421OtherBLUE CROSS
6523OtherVYTRA
AB45739OtherMDNY
6523OtherVYTRA
97942OtherUSHC
522421OtherBLUE CROSS