Basic Information
| Provider Information | |||||||||
| NPI: | 1366426074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207956183 | ||||||||
| FaxNumber: | 5207956361 | ||||||||
| Practice Location | |||||||||
| Address1: | 1669 W INA RD | ||||||||
| Address2: | SUITE 141 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857041982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207956183 | ||||||||
| FaxNumber: | 5207956361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
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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 | 207Q00000X | 5203 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 425026 | 05 | AZ | MEDICAID | P00435437 | 01 | AZ | RAIL ROAD MEDICARE | OTHER |