Provider Demographics
NPI:1700874922
Name:GOLDSTEIN, JAMES R (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 LAKE LAND BLVD
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5562
Mailing Address - Country:US
Mailing Address - Phone:217-258-8466
Mailing Address - Fax:217-258-8443
Practice Address - Street 1:1120 LAKE LAND BLVD
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5562
Practice Address - Country:US
Practice Address - Phone:217-258-8466
Practice Address - Fax:217-258-8443
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007322152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007322Medicaid
IL677320Medicare ID - Type Unspecified