Provider Demographics
NPI:1457443228
Name:GOLDSTEIN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GOLDSTEIN
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 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7280
Mailing Address - Fax:423-439-7314
Practice Address - Street 1:325 N STATE OF FRANKLIN RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-439-7280
Practice Address - Fax:423-493-7314
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNVAD0000Medicare UPIN