Provider Demographics
NPI:1770588733
Name:GOLDSTEIN, KENNETH H (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 805
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-309-8680
Mailing Address - Fax:904-345-5841
Practice Address - Street 1:2161 KINGSLEY AVE.
Practice Address - Street 2:SUITE 200
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-276-2303
Practice Address - Fax:904-272-3659
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 37834207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4230901OtherAETNA
FL043429900Medicaid
FL204230OtherAVMED
FL55131OtherBCBS
FL55131VMedicare PIN
FL4230901OtherAETNA
FLP00189922Medicare PIN
FL55131AMedicare PIN
FL55131UMedicare PIN