Basic Information
| Provider Information | |||||||||
| NPI: | 1194749804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 S MANNING BLVD STE 106 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184380507 | ||||||||
| FaxNumber: | 5184380981 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128666049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185830111 | ||||||||
| FaxNumber: | 5185832426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 122833 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 10000778 | 01 | NY | CDP | OTHER | 4145855 | 01 | NY | MVP | OTHER | 000434084003 | 01 | NY | BLUE SHIELD OF NORTHEASTE | OTHER | 105151 | 01 | NY | GHI HMO | OTHER | 7846749 | 01 | NY | AETNA | OTHER |