Provider Demographics
NPI:1225187164
Name:GOOLDY, SAMUEL K (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:K
Last Name:GOOLDY
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 1:1 OXFORD RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2651
Mailing Address - Country:US
Mailing Address - Phone:315-724-6611
Mailing Address - Fax:315-724-6366
Practice Address - Street 1:1 OXFORD RD
Practice Address - Street 2:SUITE 304
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2651
Practice Address - Country:US
Practice Address - Phone:315-724-6611
Practice Address - Fax:315-724-6366
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00582774Medicaid
40075DMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
40075AMedicare ID - Type UnspecifiedGROUP NUMBER
NYB82226Medicare UPIN