Provider Demographics
NPI:1952432585
Name:GOLDSTEIN, GARY ROY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROY
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-1247
Mailing Address - Country:US
Mailing Address - Phone:740-852-0717
Mailing Address - Fax:740-852-0828
Practice Address - Street 1:61 E HIGH ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-1247
Practice Address - Country:US
Practice Address - Phone:740-852-0717
Practice Address - Fax:740-852-0828
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1117111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000309381OtherANTHEM
OHLO9342041Medicare ID - Type Unspecified