Provider Demographics
NPI:1013674837
Name:GOLDSTEIN, STUART CHARLES
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:CHARLES
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-7484
Mailing Address - Country:US
Mailing Address - Phone:208-310-2125
Mailing Address - Fax:
Practice Address - Street 1:1010 RANCH RD
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-7484
Practice Address - Country:US
Practice Address - Phone:208-310-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-67132083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine