MEDICARE: GOLDEN STATE FAMILY CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1578345625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN STATE FAMILY CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 18025
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92817-8025
Country	:	US
Telephone Number	:	941-720-0731
Fax Number	:

Provider Business Practice Location Address
First Line	:	4082 WHITTIER BLVD STE 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-2559
Country	:	US
Telephone Number	:	323-347-5757
Fax Number	:	323-264-2671

Authorized Official
Title or Position	:	CEO
Name	:	HAROLD TABAIE
Credential	:	DO
Telephone Number	:	941-720-0731

Provider Enumeration Date	:	10/13/2023
Last Update Date	:	10/13/2023

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Directions to “GOLDEN STATE FAMILY CLINIC ” Practice Location

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