Provider Demographics
NPI:1598934838
Name:GOLDEN GATE FAMILY CLINIC
Entity Type:Organization
Organization Name:GOLDEN GATE FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VAVA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:NYANUDOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-775-3100
Mailing Address - Street 1:5475 GOLDEN GATE PKWY
Mailing Address - Street 2:SUITE # 7
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-7529
Mailing Address - Country:US
Mailing Address - Phone:239-775-3100
Mailing Address - Fax:239-775-3107
Practice Address - Street 1:5475 GOLDEN GATE PKWY
Practice Address - Street 2:SUITE # 7
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7529
Practice Address - Country:US
Practice Address - Phone:239-775-3100
Practice Address - Fax:239-775-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty