Basic Information
| Provider Information | |||||||||
| NPI: | 1376792390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAUL J. GOLDMAN,MD DIAGNOSTIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 W ROSEDALE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381131 | ||||||||
| FaxNumber: | 8178771511 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 PALUXY RD | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760485655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159286268 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOLDMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | JAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8173381131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 083588601 | 05 | TX | MEDICAID |