Provider Demographics
NPI:1174506620
Name:GOLDSTEIN, KEN EVAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:EVAN
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400D HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3026
Mailing Address - Country:US
Mailing Address - Phone:540-347-9393
Mailing Address - Fax:540-347-9398
Practice Address - Street 1:400D HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3026
Practice Address - Country:US
Practice Address - Phone:540-347-9393
Practice Address - Fax:540-347-9398
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000671213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9302158Medicaid
VA0926860001Medicare NSC
VA9302158Medicaid
VA480002926AMedicare PIN
DC470086Medicare PIN
VA480000558Medicare PIN