Provider Demographics
NPI:1508139957
Name:GOLDEN STATE BONE AND JOINT CLINIC
Entity Type:Organization
Organization Name:GOLDEN STATE BONE AND JOINT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:ENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-858-3880
Mailing Address - Street 1:9033 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-1847
Mailing Address - Country:US
Mailing Address - Phone:310-858-3800
Mailing Address - Fax:888-589-6241
Practice Address - Street 1:9033 WILSHIRE BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-1847
Practice Address - Country:US
Practice Address - Phone:310-858-3800
Practice Address - Fax:888-589-6241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100628207X00000X, 207XS0106X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFU255AMedicare PIN
CA6685440001Medicare NSC