Provider Demographics
NPI:1245411370
Name:GOLDIN, BRADLEY SCOTT
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SCOTT
Last Name:GOLDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-2113
Mailing Address - Country:US
Mailing Address - Phone:516-295-6830
Mailing Address - Fax:516-295-6499
Practice Address - Street 1:1338 BROADWAY
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-2113
Practice Address - Country:US
Practice Address - Phone:516-295-6830
Practice Address - Fax:516-295-6499
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01879529Medicaid