Provider Demographics
NPI:1891710976
Name:GOLDSTEIN, ELLIE JC (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:JC
Last Name:GOLDSTEIN
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 2:740E
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2208
Mailing Address - Country:US
Mailing Address - Phone:310-315-1511
Mailing Address - Fax:310-315-3662
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:740E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2208
Practice Address - Country:US
Practice Address - Phone:310-315-1511
Practice Address - Fax:310-315-3662
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30475207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91289Medicare UPIN