Provider Demographics
NPI:1487652137
Name:GOLDSTEIN, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
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 1:166 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2803
Mailing Address - Country:US
Mailing Address - Phone:508-583-0360
Mailing Address - Fax:508-583-0330
Practice Address - Street 1:166 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2803
Practice Address - Country:US
Practice Address - Phone:508-583-0360
Practice Address - Fax:508-583-0330
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36668208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2054981Medicaid
B74826Medicare UPIN
MAJ03196Medicare ID - Type Unspecified
MAJ03196Medicare PIN