Provider Demographics
NPI:1568520708
Name:GOLUB, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:GOLUB
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 1:118 NORTH COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-473-7171
Mailing Address - Fax:631-473-4605
Practice Address - Street 1:118 NORTH COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-473-7171
Practice Address - Fax:631-473-4605
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142187207VG0400X
NY1421871207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1421871OtherSTATE LIC
NY1461871OtherNYS LICENSE
NYAG9351800OtherDEA
67A401Medicare ID - Type Unspecified
B17744Medicare UPIN