Provider Demographics
NPI:1578569133
Name:GOLDSMITH, DEIDRE VIAN (CRNA)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:VIAN
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SHIRECREST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3965
Mailing Address - Country:US
Mailing Address - Phone:443-831-0093
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR141638367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD178200200Medicaid
MD454MH697OtherTRAILBLAZER