Provider Demographics
NPI:1700973203
Name:GOLDSTEIN, CRAIG RUSSELL (DOMD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:RUSSELL
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:DOMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NORTHFIELD AVENUE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-325-2103
Mailing Address - Fax:973-325-2254
Practice Address - Street 1:111 NORTHFIELD AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-325-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07799900207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I38461Medicare UPIN
NJ093712Medicare ID - Type Unspecified