Provider Demographics
NPI:1659473239
Name:GOLDSTEIN, KENNETH BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRIAN
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 1:1000 BIRCHFIELD DRIVE
Mailing Address - Street 2:SUITE 1004
Mailing Address - City:MT. LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054
Mailing Address - Country:US
Mailing Address - Phone:856-866-1557
Mailing Address - Fax:856-231-7955
Practice Address - Street 1:1000 BIRCHFIELD DRIVE
Practice Address - Street 2:SUITE 1004
Practice Address - City:MT. LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054
Practice Address - Country:US
Practice Address - Phone:856-866-1557
Practice Address - Fax:856-231-7955
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05323200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE23848Medicare UPIN