Provider Demographics
NPI:1982678785
Name:GOLDMAN, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:GOLDMAN
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 1:920 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1524
Mailing Address - Country:US
Mailing Address - Phone:706-649-6600
Mailing Address - Fax:706-649-6614
Practice Address - Street 1:920 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1524
Practice Address - Country:US
Practice Address - Phone:706-649-6600
Practice Address - Fax:706-649-6614
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014360208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52022031-003OtherBCBS
AL2350OtherBCBS
GA000017586AMedicaid
GA20011741OtherRAILROAD MEDICARE
GA52022031-003OtherBCBS