Provider Demographics
NPI:1417453168
Name:JACOB B GOLDSTEIN DPM LLC
Entity Type:Organization
Organization Name:JACOB B GOLDSTEIN DPM LLC
Other - Org Name:FOOT PAIN CENTER OF KANSAS CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:913-856-8150
Mailing Address - Street 1:230 E MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-1643
Mailing Address - Country:US
Mailing Address - Phone:913-856-8150
Mailing Address - Fax:
Practice Address - Street 1:1402 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-3529
Practice Address - Country:US
Practice Address - Phone:785-893-0494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOT PAIN CENTER OF KANSAS CITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12-00358213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty