Provider Demographics
NPI:1740888155
Name:GOLDFOOT, CHARLES SAMUEL
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SAMUEL
Last Name:GOLDFOOT
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 1:1650 NW 13TH AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3694
Mailing Address - Country:US
Mailing Address - Phone:971-340-6523
Mailing Address - Fax:
Practice Address - Street 1:1650 NW 13TH AVE APT 109
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3694
Practice Address - Country:US
Practice Address - Phone:971-340-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program