Provider Demographics
NPI:1265545974
Name:GOLDFADEN, GARY L (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:GOLDFADEN
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 1:3816 HOLLYWOOD BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6750
Mailing Address - Country:US
Mailing Address - Phone:954-966-5409
Mailing Address - Fax:954-966-0852
Practice Address - Street 1:3816 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6750
Practice Address - Country:US
Practice Address - Phone:954-966-5409
Practice Address - Fax:954-966-0852
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13631174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD51737Medicare UPIN
FL06845Medicare ID - Type Unspecified