Provider Demographics
NPI:1952392110
Name:GOLDSTEIN, GARY R (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11133 DUNN RD
Mailing Address - Street 2:SUITE 2335
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6119
Mailing Address - Country:US
Mailing Address - Phone:314-653-5007
Mailing Address - Fax:314-653-4149
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:SUITE 2335
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-653-5007
Practice Address - Fax:314-653-4149
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMOR3M34207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202810412Medicaid
290007537OtherRAILROAD MEDICARE INDIVIDUAL ID
CE7661OtherRAILROAD MEDICARE
290009907OtherRAILROAD MEDICARE PCI ID
MO000010902Medicare PIN
MO000010417Medicare PIN
290007537OtherRAILROAD MEDICARE INDIVIDUAL ID
MO005010902Medicare PIN
CE7661OtherRAILROAD MEDICARE
290009907OtherRAILROAD MEDICARE PCI ID
MOE63340Medicare UPIN
MO202810412Medicaid
MO005010417Medicare PIN