Basic Information
Provider Information | |||||||||
NPI: | 1952405037 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDSTONE | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1930 BRANNAN RD | ||||||||
Address2: |   | ||||||||
City: | MCDONOUGH | ||||||||
State: | GA | ||||||||
PostalCode: | 302534310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6782844040 | ||||||||
FaxNumber: | 6782844076 | ||||||||
Practice Location | |||||||||
Address1: | 5730 GLENRIDGE DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303285579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042561844 | ||||||||
FaxNumber: | 4042563499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2006 | ||||||||
LastUpdateDate: | 08/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036755 | GA | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | BG2261383 | 01 |   | DEA | OTHER | 000539613A | 05 | GA |   | MEDICAID | 340008501 | 01 | GA | RAILROAD MEDICARE | OTHER |