Provider Demographics
NPI:1417211533
Name:GOLD STANDARD UROLOGY
Entity Type:Organization
Organization Name:GOLD STANDARD UROLOGY
Other - Org Name:GOLD STANDARD UROLOGY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-750-7675
Mailing Address - Street 1:4859 W SLAUSON AVE
Mailing Address - Street 2:#305
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1290
Mailing Address - Country:US
Mailing Address - Phone:213-750-7675
Mailing Address - Fax:888-534-5766
Practice Address - Street 1:617 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-5718
Practice Address - Country:US
Practice Address - Phone:213-750-7675
Practice Address - Fax:888-534-5766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100321208600000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty