Provider Demographics
NPI:1982603247
Name:GOLDIS, MICHAEL E (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:GOLDIS
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 1:119 LAUREL RD E
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1324
Mailing Address - Country:US
Mailing Address - Phone:856-346-3469
Mailing Address - Fax:856-346-9456
Practice Address - Street 1:119 LAUREL RD E
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1324
Practice Address - Country:US
Practice Address - Phone:856-346-3469
Practice Address - Fax:856-346-9456
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-07-15
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
NJMB57688207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6141005Medicaid
NJF78301Medicare UPIN
NJ766317Medicare ID - Type Unspecified