Provider Demographics
NPI:1407995384
Name:GOYZUETA, JUAN DOMINGO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:DOMINGO
Last Name:GOYZUETA
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:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:NY
Mailing Address - Zip Code:10921-0284
Mailing Address - Country:US
Mailing Address - Phone:845-651-2478
Mailing Address - Fax:845-651-2479
Practice Address - Street 1:139 FORESTBURGH RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-2348
Practice Address - Country:US
Practice Address - Phone:845-791-1624
Practice Address - Fax:845-791-1689
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178009207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01617569Medicaid
F89610Medicare UPIN
86J271Medicare PIN