Provider Demographics
NPI:1811901044
Name:GOLDSTEIN, GLENN LEE (DO)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:LEE
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SULLIVAN ST
Mailing Address - Street 2:APT 4E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-4800
Mailing Address - Country:US
Mailing Address - Phone:646-379-0972
Mailing Address - Fax:
Practice Address - Street 1:348 13TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-5004
Practice Address - Country:US
Practice Address - Phone:718-788-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185944208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3Y0081Medicare ID - Type Unspecified
NYG87562Medicare UPIN