Provider Demographics
NPI:1194784116
Name:GOLDSTEIN, KENNETH TODD (DPM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:TODD
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:6325 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5822
Practice Address - Country:US
Practice Address - Phone:716-630-1295
Practice Address - Fax:716-250-5999
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002721213E00000X
NY002721213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00588683Medicaid
NY034663Medicare ID - Type Unspecified
T25880Medicare UPIN