Provider Demographics
NPI:1972610103
Name:GOLDMAN, EDWARD MARK (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARK
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 1:100 E SCHUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-3556
Mailing Address - Country:US
Mailing Address - Phone:915-542-3059
Mailing Address - Fax:915-533-2504
Practice Address - Street 1:100 E SCHUSTER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3556
Practice Address - Country:US
Practice Address - Phone:915-542-3059
Practice Address - Fax:915-533-2504
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9208174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134873202Medicaid
00LF67Medicare ID - Type Unspecified
TX134873202Medicaid