Provider Demographics
NPI:1316039142
Name:GOLDMAN, JEFFREY HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HOWARD
Last Name:GOLDMAN
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 1:4100 PARK FOREST DR.
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2058
Mailing Address - Country:US
Mailing Address - Phone:231-935-5710
Mailing Address - Fax:231-935-9045
Practice Address - Street 1:4100 PARK FOREST DR.
Practice Address - Street 2:SUITE 208
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-5710
Practice Address - Fax:231-935-9045
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301095691207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0280037OtherBCBSM
MI1316039142Medicaid
MIM83990011Medicare PIN
MI1316039142Medicaid