Provider Demographics
NPI:1366426074
Name:GOLDMAN, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GOLDMAN
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:520-795-6183
Mailing Address - Fax:520-795-6361
Practice Address - Street 1:2355 N WYATT DR STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2120
Practice Address - Country:US
Practice Address - Phone:520-616-4948
Practice Address - Fax:520-616-4958
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5203207Q00000X
AZ30642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ425026Medicaid
AZP00435437OtherRAIL ROAD MEDICARE
AZG67989Medicare UPIN
AZP00435437OtherRAIL ROAD MEDICARE
AZ425026Medicaid