Provider Demographics
NPI:1194820423
Name:GOLDMAN, I SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:I
Middle Name:SCOTT
Last Name:GOLDMAN
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 1:400 N MOUNTAIN AVENUE
Mailing Address - Street 2:STE 310
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-920-0876
Mailing Address - Fax:909-982-0784
Practice Address - Street 1:400 N MOUNTAIN AVENUE
Practice Address - Street 2:STE 310
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-920-0876
Practice Address - Fax:909-982-0784
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42592207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA125762100OtherDEPARTMENT OF LABOR IDENTIFICATION
CA200005004OtherMEDICARE RAILROAD PIN
CA0590570001Medicare NSC
CA125762100OtherDEPARTMENT OF LABOR IDENTIFICATION
CA200005004OtherMEDICARE RAILROAD PIN