Provider Demographics
NPI:1548388846
Name:GOLDSTEIN, DEBORAH (APN)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 N PONTIAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1042
Mailing Address - Country:US
Mailing Address - Phone:773-625-6985
Mailing Address - Fax:312-864-9906
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-4150
Practice Address - Fax:312-864-9906
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-239547163WD0400X
IL209-000191363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ16039Medicare UPIN