Provider Demographics
NPI:1225117138
Name:GOLDSTEIN, ILENE JOY (MD)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:JOY
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:954-315-5750
Mailing Address - Fax:954-733-5004
Practice Address - Street 1:10301 HAGEN RANCH RD STE 760
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3777
Practice Address - Country:US
Practice Address - Phone:954-315-5750
Practice Address - Fax:954-733-5004
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1193132080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104776000Medicaid
NYF74323Medicare UPIN
NY01545133Medicaid