Provider Demographics
NPI:1225129166
Name:GOLD, JEFFREY IRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:IRA
Last Name:GOLD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3701 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2814
Mailing Address - Country:US
Mailing Address - Phone:323-669-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS# 12
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2262
Practice Address - Fax:323-660-8983
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19530103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY195300Medicaid