Provider Demographics
NPI:1639674195
Name:GOLDART, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:GOLDART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 E HOSPITAL DR # CW-11712
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-4000
Mailing Address - Country:US
Mailing Address - Phone:301-518-8076
Mailing Address - Fax:
Practice Address - Street 1:1540 E HOSPITAL DR # CW-11712
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4000
Practice Address - Country:US
Practice Address - Phone:301-518-8076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43015040492080P0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program