Provider Demographics
NPI:1871580845
Name:GOLDSTEIN, LESLIE S (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:S
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 1:258 HOOSICK ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2427
Mailing Address - Country:US
Mailing Address - Phone:518-274-5660
Mailing Address - Fax:518-274-5666
Practice Address - Street 1:258 HOOSICK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2427
Practice Address - Country:US
Practice Address - Phone:518-274-5660
Practice Address - Fax:518-274-5666
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157862174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000405271001OtherBLUE SHIELD OF NENY
NY00844633Medicaid
NY0076113OtherGHI
NY10000785OtherCDPHP
NY27123OtherMVP
NY51E511OtherEMPIRE BLUE CROSS
NY0076113OtherGHI
NYD01877Medicare UPIN