Provider Demographics
NPI:1427013374
Name:GOLDMAN, JONATHON DREW (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:DREW
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 1:21 E HURON ST
Mailing Address - Street 2:#1304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3925
Mailing Address - Country:US
Mailing Address - Phone:312-649-1329
Mailing Address - Fax:
Practice Address - Street 1:541 N FAIRBANKS CT
Practice Address - Street 2:SITOE 2719
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3319
Practice Address - Country:US
Practice Address - Phone:312-649-1329
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601860OtherBLUE CROSS BLUE SHIELD
IL762520Medicare ID - Type Unspecified