Healthcare Provider Details

I. General information

NPI: 1407947047
Provider Name (Legal Business Name): GERALD GOLNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6702 N 19TH AVE
PHOENIX AZ
85015-1101
US

IV. Provider business mailing address

4434 N 12TH STREET
PHOENIX AZ
85014-1101
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-5121
  • Fax: 602-242-6945
Mailing address:
  • Phone: 602-242-5121
  • Fax: 602-242-6945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number5814
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: