Provider Demographics
NPI:1578797866
Name:GOLDSCHMIDT, MARK WILLIAM (IDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:GOLDSCHMIDT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-515 MEHAME PL
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-5813
Mailing Address - Country:US
Mailing Address - Phone:619-392-3314
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 9, SCHOFIELD BARRACKS
Practice Address - Street 2:
Practice Address - City:SCHOFIELD BARRACKS
Practice Address - State:HI
Practice Address - Zip Code:96857
Practice Address - Country:US
Practice Address - Phone:808-655-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman