Provider Demographics
NPI:1679629778
Name:GOLDSTEIN, DEBRA A (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 W TAYLOR ST
Mailing Address - Street 2:2.50 EEI, M/C 648
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3731
Mailing Address - Country:US
Mailing Address - Phone:312-996-6660
Mailing Address - Fax:312-355-0520
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-088837207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
L52667Medicare ID - Type Unspecified
F92783Medicare UPIN