Provider Demographics
NPI:1629001078
Name:GOLDKORN, RONEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RONEN
Middle Name:
Last Name:GOLDKORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64321207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A643210Medicaid
CA1902846306OtherGROUP NPI
CAGR0100430OtherGRPUP MEDICAL
CA00A643210197OtherCAL OPTIMA
CAW18762OtherGROUP MEDICARE
CACE1617OtherGROUP RAILROAD MEDICARE
CAP00322106OtherRAILROAD MEDICARE
CAGR0016910OtherGROUP MEDICAID
CAZZZ50018ZOtherGROUP BLUE SHIELD
CA06E2774OtherGROUP CHAMPUS
CA00A643210OtherBLUE SHIELD
CA1356390009OtherGROUP NPI
CAW11675OtherGROUP MEDICARE
CAGR0100430OtherGRPUP MEDICAL
CA00A643210OtherBLUE SHIELD