Provider Demographics
NPI:1194778878
Name:GOLDIE, GAINNEOS R (MD)
Entity type:Individual
Prefix:
First Name:GAINNEOS
Middle Name:R
Last Name:GOLDIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 HIGHWAY 124
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4614
Mailing Address - Country:US
Mailing Address - Phone:770-978-1331
Mailing Address - Fax:770-978-8580
Practice Address - Street 1:3020 HIGHWAY 124
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-4614
Practice Address - Country:US
Practice Address - Phone:770-978-1331
Practice Address - Fax:770-978-8580
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0735207R00000X
GA87599207RG0300X, 207R00000X
PAMD447980207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W8852OtherBLUE CROSS BLUE SHIELD
TX175370901Medicaid
TX175370903Medicaid
TX175370902Medicaid
TX8G3133Medicare PIN
TX175370901Medicaid