Provider Demographics
NPI:1780131011
Name:EVAN GOLDSTEIN, D.O., INC., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:EVAN GOLDSTEIN, D.O., INC., A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-206-1501
Mailing Address - Street 1:9033 WILSHIRE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1836
Mailing Address - Country:US
Mailing Address - Phone:212-206-1501
Mailing Address - Fax:888-880-8621
Practice Address - Street 1:9033 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1836
Practice Address - Country:US
Practice Address - Phone:212-206-1501
Practice Address - Fax:888-880-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 14799208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty