Provider Demographics
NPI:1578681391
Name:GOLDLUST, ERIC JONATHAN (MD, PHD)
Entity Type:Individual
Prefix:PROF
First Name:ERIC
Middle Name:JONATHAN
Last Name:GOLDLUST
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:700 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083569390200000X
RIMD12635207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI939025129OtherRI MEDICARE GROUP NPI
RI007061003OtherRI MEDICARE
MA12292008OtherTUFTS
MA2157454Medicaid
RIEG72322Medicaid
RI10302008OtherNHPRI
RIP00711112OtherRAILROAD MEDICARE
RI09/30/2008OtherBCBS
RI04/15/2009OtherUNITED HEALTHCARE