Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 1678 | ME |
N | 207Q00000X | Family Doctor | 1678 | ME |
NPI | 1003892605 |
---|---|
Provider Name | Stephen R Goldbas |
First Address | Freeport, ME 04032-6145 |
Second Address | Portland, ME 04102-2780 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2005 |
Last Update Date | 14/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003892605 | (05) | ME |
F51960 | (02) | ME |