Provider Demographics
NPI:1770509853
Name:GOLDSTEIN, ALISA ESTHER (DO)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:ESTHER
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-0518
Mailing Address - Country:US
Mailing Address - Phone:323-632-5506
Mailing Address - Fax:
Practice Address - Street 1:5560 WILDRIDGE LN
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4001
Practice Address - Country:US
Practice Address - Phone:323-632-5506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010136072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII57106Medicare UPIN