Basic Information
Provider Information | |||||||||
NPI: | 1467427633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDWASSER | ||||||||
FirstName: | STEVE | ||||||||
MiddleName: | ERIC | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 25317 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336225317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132860033 | ||||||||
FaxNumber: | 8132821806 | ||||||||
Practice Location | |||||||||
Address1: | 400 COLONNADE DR STE 230 | ||||||||
Address2: |   | ||||||||
City: | PONTE VEDRA | ||||||||
State: | FL | ||||||||
PostalCode: | 320816237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9046408249 | ||||||||
FaxNumber: | 9046408250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2006 | ||||||||
LastUpdateDate: | 10/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VF0040X | ME80864 | FL | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 2088F0040X | ME80864 | FL | Y |   | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
ID | Type | State | Issuer | Description | 000876356A | 05 | GA |   | MEDICAID | 259352100 | 05 | FL |   | MEDICAID |