Provider Demographics
NPI:1306399951
Name:GOTHAM PSYCHIATRIC PC
Entity Type:Organization
Organization Name:GOTHAM PSYCHIATRIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-814-0040
Mailing Address - Street 1:600 N BRAND BLVD STE 640
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4215
Mailing Address - Country:US
Mailing Address - Phone:213-814-0040
Mailing Address - Fax:917-338-1381
Practice Address - Street 1:5419 HOLLYWOOD BLVD STE C172
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-3480
Practice Address - Country:US
Practice Address - Phone:213-814-0040
Practice Address - Fax:917-338-1381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1410462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty