Provider Demographics
NPI:1912452020
Name:GOLDSTEIN, JACKI (MD)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 OLD FARMS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-3714
Mailing Address - Country:US
Mailing Address - Phone:860-833-5732
Mailing Address - Fax:
Practice Address - Street 1:40 OLD FARMS RD
Practice Address - Street 2:
Practice Address - City:SOUTH GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073-3714
Practice Address - Country:US
Practice Address - Phone:860-833-5732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026132207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine