Provider Demographics
NPI:1902829112
Name:GOLDMAN, YEVGENIY SR (MD)
Entity Type:Individual
Prefix:DR
First Name:YEVGENIY
Middle Name:
Last Name:GOLDMAN
Suffix:SR
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 1:3659 HOLT LANE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-1909
Mailing Address - Country:US
Mailing Address - Phone:215-698-9295
Mailing Address - Fax:215-698-0127
Practice Address - Street 1:9867 B BUSTLETON AVE
Practice Address - Street 2:BUSTLETON HEALTH CARE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2611
Practice Address - Country:US
Practice Address - Phone:215-698-9295
Practice Address - Fax:215-698-0127
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070403L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017914290004Medicaid
PAH12185Medicare UPIN
PA036407Medicare ID - Type Unspecified