Provider Demographics
NPI:1659335636
Name:GOLDSTEIN, MITCHELL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ROBERT
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 1:107 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2920
Mailing Address - Country:US
Mailing Address - Phone:574-246-1036
Mailing Address - Fax:574-246-1634
Practice Address - Street 1:107 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2920
Practice Address - Country:US
Practice Address - Phone:574-246-1036
Practice Address - Fax:574-246-1634
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010415752084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100346980BMedicaid
IN100346980AMedicaid
INF65385Medicare UPIN
IN100346980AMedicaid
IN651990PMedicare ID - Type Unspecified