Provider Demographics
NPI:1982689469
Name:GOLDSTEIN, LARRY I (DPM)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:I
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:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-0012
Mailing Address - Country:US
Mailing Address - Phone:978-470-3495
Mailing Address - Fax:978-475-5110
Practice Address - Street 1:41 BERLIN AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5103
Practice Address - Country:US
Practice Address - Phone:978-470-3495
Practice Address - Fax:978-475-5110
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2011-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1450213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0327549Medicaid
MAT58668Medicare UPIN
MA0327549Medicaid