Provider Demographics
NPI:1861807679
Name:GOLDSTEIN, ITAMAR LIOR (MD)
Entity type:Individual
Prefix:
First Name:ITAMAR
Middle Name:LIOR
Last Name:GOLDSTEIN
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 1:450 CLARKSON AVE
Mailing Address - Street 2:BOX 1228
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2012
Mailing Address - Country:US
Mailing Address - Phone:718-245-4790
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:BOX 1228
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:718-245-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY297597207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program