Healthcare Provider Details

I. General information

NPI: 1053538694
Provider Name (Legal Business Name): THEODORE B. GOLDSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S SPALDING DR SUITE 400
BEVERLY HILLS CA
90212-1800
US

IV. Provider business mailing address

120 S SPALDING DR SUITE 400
BEVERLY HILLS CA
90212-1800
US

V. Phone/Fax

Practice location:
  • Phone: 310-860-3450
  • Fax:
Mailing address:
  • Phone: 310-860-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG13277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: