Provider Demographics
NPI:1225020639
Name:GOLDSTEIN, MARTIN I (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:I
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 1:3001 S COBB DR SE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-7809
Mailing Address - Country:US
Mailing Address - Phone:770-436-6216
Mailing Address - Fax:770-434-2323
Practice Address - Street 1:3001 S COBB DR SE
Practice Address - Street 2:SUITE 203
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7809
Practice Address - Country:US
Practice Address - Phone:770-436-6216
Practice Address - Fax:770-434-2323
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE53965Medicare UPIN
GA07BBSQMMedicare ID - Type Unspecified