Provider Demographics
NPI:1669504130
Name:GOLDMAN, PAUL RUSSELL (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:RUSSELL
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:GOLDMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:19 MANSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-4033
Mailing Address - Country:US
Mailing Address - Phone:516-566-1398
Mailing Address - Fax:516-799-4542
Practice Address - Street 1:19 MANSFIELD DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-4033
Practice Address - Country:US
Practice Address - Phone:516-566-1398
Practice Address - Fax:516-799-4542
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02046179Medicaid
NY02046179Medicaid