Provider Demographics
NPI:1619038080
Name:GOLDFADEN, DANIEL MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MICHAEL
Last Name:GOLDFADEN
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:504 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1416
Practice Address - Country:US
Practice Address - Phone:706-235-3855
Practice Address - Fax:706-290-2399
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028988208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000330371AMedicaid
D29583Medicare UPIN
GA000330371AMedicaid