Provider Demographics
NPI:1649251810
Name:GOLDMAN, LARY S (MD)
Entity type:Individual
Prefix:DR
First Name:LARY
Middle Name:S
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 1:30335 W 13 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2262
Mailing Address - Country:US
Mailing Address - Phone:248-419-3400
Mailing Address - Fax:248-419-3410
Practice Address - Street 1:30335 W 13 MILE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2262
Practice Address - Country:US
Practice Address - Phone:248-419-3400
Practice Address - Fax:248-419-3410
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045138207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1816063Medicaid
0F36003001Medicare ID - Type Unspecified
MI1816063Medicaid