Provider Demographics
NPI:1205800455
Name:GOLDMAN, LAURA N (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:N
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 ALBANY ST
Mailing Address - Street 2:DOWLING 5 SOUTH
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2525
Mailing Address - Country:US
Mailing Address - Phone:617-414-4465
Mailing Address - Fax:617-414-3345
Practice Address - Street 1:409 W BROADWAY
Practice Address - Street 2:DEPT FAMILY MEDICINE
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2245
Practice Address - Country:US
Practice Address - Phone:617-269-7500
Practice Address - Fax:617-464-7524
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56550207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3003434Medicaid
MAB73597Medicare UPIN
MAC20270Medicare ID - Type Unspecified