Provider Demographics
NPI:1972584977
Name:GOLDSTEIN, LARRY S (DPM)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:S
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE STE 900
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3084
Mailing Address - Country:US
Mailing Address - Phone:678-426-2171
Mailing Address - Fax:404-446-1957
Practice Address - Street 1:1200 RUSSELL PKWY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5540
Practice Address - Country:US
Practice Address - Phone:478-328-2008
Practice Address - Fax:478-918-0276
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000722213ES0103X
GAPOD000722213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00686472OtherRAILROAD MEDICARE
GAP00686472OtherRAILROAD MEDICARE
GAT93083Medicare UPIN