Provider Demographics
NPI:1508934977
Name:DAVID S. GOTHELF, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DAVID S. GOTHELF, A PROFESSIONAL CORPORATION
Other - Org Name:DESERT FAMILY MEDICINE OF GREEN VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOTHELF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:702-269-9995
Mailing Address - Street 1:100 N GREEN VALLEY PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-6391
Mailing Address - Country:US
Mailing Address - Phone:702-269-9995
Mailing Address - Fax:702-944-4056
Practice Address - Street 1:100 N GREEN VALLEY PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-6391
Practice Address - Country:US
Practice Address - Phone:702-269-9995
Practice Address - Fax:702-944-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV479207Q00000X
NV1100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V37894Medicare PIN