Provider Demographics
NPI:1639140403
Name:GOLDMAN, JAROSLAV ISAK (MD)
Entity Type:Individual
Prefix:DR
First Name:JAROSLAV
Middle Name:ISAK
Last Name:GOLDMAN
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 1:6420 N. CALIFORNIA AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645
Mailing Address - Country:US
Mailing Address - Phone:773-973-6100
Mailing Address - Fax:773-262-4882
Practice Address - Street 1:6420 N. CALIFORNIA AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645
Practice Address - Country:US
Practice Address - Phone:773-973-6100
Practice Address - Fax:773-262-4882
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-100764207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-100764Medicaid
IL555810Medicare ID - Type Unspecified
IL036-100764Medicaid