Provider Demographics
NPI:1184154502
Name:GOSHORN, ELI SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:SAMUEL
Last Name:GOSHORN
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 1:140 BERGEN STREET
Mailing Address - Street 2:AMBULATORY CARE CENTER LEVEL D
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103
Mailing Address - Country:US
Mailing Address - Phone:973-972-5111
Mailing Address - Fax:
Practice Address - Street 1:140 BERGEN STREET
Practice Address - Street 2:AMBULATORY CARE CENTER LEVEL D
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11491400207RI0200X
PAMT213386390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program