Provider Demographics
NPI:1245233261
Name:GOLDSTEIN, JACK D (MD1208)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:MD1208
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 MASSASOIT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:E PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-2012
Mailing Address - Country:US
Mailing Address - Phone:401-919-5222
Mailing Address - Fax:401-919-5227
Practice Address - Street 1:400 MASSASOIT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:E PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2012
Practice Address - Country:US
Practice Address - Phone:401-919-5222
Practice Address - Fax:401-919-5227
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIRI8073207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI15131OtherNEIGHBORHOOD HEALTH
RI2432493OtherAETNA US HEALTHCARE
RI779577OtherTUFTS
RI200042974OtherRAILROAD MEDICARE
RI2797369003OtherCIGNA
PR0900689OtherUNITED HEALTHCARE
RI0000022384OtherRI BLUE CROSS BLUE SHIELD
RI202113OtherRI BLUE CHIP
RI9020116Medicaid
RI61829OtherHARVARD PILGRIM HEALTH CA
RI200042974OtherRAILROAD MEDICARE
RI209022384Medicare PIN