Provider Demographics
NPI:1427239581
Name:GOLDSTON, CHARLES BRIAN (DC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRIAN
Last Name:GOLDSTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11115 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3352
Mailing Address - Country:US
Mailing Address - Phone:503-256-4830
Mailing Address - Fax:503-255-0758
Practice Address - Street 1:11115 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3352
Practice Address - Country:US
Practice Address - Phone:503-256-4830
Practice Address - Fax:503-255-0758
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3772111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR140119Medicare PIN