Provider Demographics
NPI:1386758852
Name:GOLDSTEIN, SHELDON J (DPM)
Entity type:Individual
Prefix:
First Name:SHELDON
Middle Name:J
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 1:3560 PONTIAC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2337
Mailing Address - Country:US
Mailing Address - Phone:248-674-2575
Mailing Address - Fax:248-674-0577
Practice Address - Street 1:3560 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2337
Practice Address - Country:US
Practice Address - Phone:248-674-2575
Practice Address - Fax:248-674-0577
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000581213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480F317540OtherBCBS
MI3418790Medicaid
MI4273392Medicaid
MIT34179Medicare UPIN
MIOM5531002Medicare ID - Type Unspecified
MI0N94460001Medicare PIN