1194820423 NPI number — I SCOTT GOLDMAN MD

Table of content: I SCOTT GOLDMAN MD (NPI 1194820423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194820423 NPI number — I SCOTT GOLDMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDMAN
Provider First Name:
I
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194820423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 N MOUNTAIN AVENUE
Provider Second Line Business Mailing Address:
STE 310
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-920-0876
Provider Business Mailing Address Fax Number:
909-982-0784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N MOUNTAIN AVENUE
Provider Second Line Business Practice Location Address:
STE 310
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-920-0876
Provider Business Practice Location Address Fax Number:
909-982-0784
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A42592 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 125762100 . This is a "DEPARTMENT OF LABOR IDENTIFICATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 200005004 . This is a "MEDICARE RAILROAD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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