Provider Demographics
NPI:1003896374
Name:GOLDSTEIN, JACOB B (DPM)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:B
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 1:230-C EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-1643
Mailing Address - Country:US
Mailing Address - Phone:913-856-8150
Mailing Address - Fax:913-856-8390
Practice Address - Street 1:230-C EAST MAIN ST.
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-1643
Practice Address - Country:US
Practice Address - Phone:913-856-8150
Practice Address - Fax:913-856-8390
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD2185213E00000X
MO2006023557213E00000X
KS12-00358KS213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3895Medicare PIN
MOMA3895001Medicare PIN
KSKA2249001Medicare PIN
MOMA3900001Medicare PIN
MOMA3900Medicare PIN
KSKA2249Medicare PIN
KS6696780001Medicare NSC