Provider Demographics
NPI:1235127077
Name:GOLDEN, JOHN THEODORE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THEODORE
Last Name:GOLDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25990 KELLY RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4483
Mailing Address - Country:US
Mailing Address - Phone:586-776-0808
Mailing Address - Fax:586-771-0953
Practice Address - Street 1:25990 KELLY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4483
Practice Address - Country:US
Practice Address - Phone:586-776-0808
Practice Address - Fax:586-771-0953
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2017-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIJG052077208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2665188Medicaid
0500374Medicare PIN
MI2665188Medicaid