Provider Demographics
NPI:1689786774
Name:GOYAL, AJAY KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:KUMAR
Last Name:GOYAL
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 1:2011 S 25TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947
Mailing Address - Country:US
Mailing Address - Phone:772-468-7020
Mailing Address - Fax:772-468-7698
Practice Address - Street 1:2011 S 25TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947
Practice Address - Country:US
Practice Address - Phone:772-468-7020
Practice Address - Fax:772-468-7698
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME744892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254137800Medicaid
G66233Medicare UPIN
FL42816Medicare ID - Type Unspecified