Provider Demographics
NPI:1750306155
Name:GOLD, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:GOLD
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 1:2021 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE # 525E
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2208
Mailing Address - Country:US
Mailing Address - Phone:310-829-2126
Mailing Address - Fax:310-998-8887
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 525E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2208
Practice Address - Country:US
Practice Address - Phone:310-829-2126
Practice Address - Fax:310-998-8887
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG478702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG478700Medicaid
G47870AMedicare PIN
CAOOG478700Medicaid