Basic Information
| Provider Information | |||||||||
| NPI: | 1790338333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LARRY S GOLDSTEIN DPM PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WARNER ROBINS FOOT AND ANKLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 RUSSELL PKWY | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310885540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783282008 | ||||||||
| FaxNumber: | 4782554364 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RUSSELL PKWY | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310885540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783282008 | ||||||||
| FaxNumber: | 4782554364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2019 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4783282008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.