Provider Demographics
NPI:1518376011
Name:GOLDEN STATE OTOLARYNGOLOGY MEDICAL
Entity Type:Organization
Organization Name:GOLDEN STATE OTOLARYNGOLOGY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUWANTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-726-6277
Mailing Address - Street 1:41301 12TH ST W
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-1464
Mailing Address - Country:US
Mailing Address - Phone:661-726-6277
Mailing Address - Fax:661-726-6291
Practice Address - Street 1:41301 12TH ST W
Practice Address - Street 2:SUITE A
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-1464
Practice Address - Country:US
Practice Address - Phone:661-726-6277
Practice Address - Fax:661-726-6291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty