Basic Information
| Provider Information | |||||||||
| NPI: | 1104868330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDEN | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 907 SUMNER ST | ||||||||
| Address2: | M201 | ||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020723374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813442325 | ||||||||
| FaxNumber: | 7813418544 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 SUMNER ST | ||||||||
| Address2: | M201 | ||||||||
| City: | STOUGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020723374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813442325 | ||||||||
| FaxNumber: | 7813418544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 45606 | MA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0163998 | 05 | MA | MEDICAID |