Provider Demographics
NPI:1851325724
Name:GOLDSTONE, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GOLDSTONE
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 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0765132086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH363568OtherWELLCARE
OHP00385110OtherRAILROAD MEDICARE
4419730OtherAETNA
OH2132801Medicaid
OHP00216359OtherRAILROAD MEDICARE
OH000000221401OtherUNISON
OH745999OtherBUCKEYE
000000503634OtherANTHEM
OH363568OtherWELLCARE
OHGO0885093Medicare PIN
000000503634OtherANTHEM