Provider Demographics
NPI:1710087630
Name:MICHAEL GOLDHAMER M. D. INC.
Entity Type:Organization
Organization Name:MICHAEL GOLDHAMER M. D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDHAMER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:619-299-2570
Mailing Address - Street 1:501 WASHINGTON ST
Mailing Address - Street 2:SUITE 508
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2231
Mailing Address - Country:US
Mailing Address - Phone:619-299-2570
Mailing Address - Fax:619-819-7259
Practice Address - Street 1:501 WASHINGTON ST
Practice Address - Street 2:SUITE 508
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-299-2570
Practice Address - Fax:619-819-7259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14025207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G140250Medicaid
CAA39152Medicare UPIN
CA00G140250Medicaid