Provider Demographics
NPI:1578754164
Name:GOLDSTEIN, MAX AUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:AUSTIN
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 1:56 BLUE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2313
Mailing Address - Country:US
Mailing Address - Phone:917-562-6534
Mailing Address - Fax:
Practice Address - Street 1:112 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2045
Practice Address - Country:US
Practice Address - Phone:860-456-6715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT049920207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program