Healthcare Provider Details

I. General information

NPI: 1508139957
Provider Name (Legal Business Name): GOLDEN STATE BONE AND JOINT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9033 WILSHIRE BLVD SUITE 403
BEVERLY HILLS CA
90210-1847
US

IV. Provider business mailing address

9033 WILSHIRE BLVD SUITE 403
BEVERLY HILLS CA
90210-1847
US

V. Phone/Fax

Practice location:
  • Phone: 310-858-3800
  • Fax: 888-589-6241
Mailing address:
  • Phone: 310-858-3800
  • Fax: 888-589-6241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA100628
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberA100628
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA100628
License Number StateCA

VIII. Authorized Official

Name: MATTHEW J. ENNA
Title or Position: OWNER
Credential: MD
Phone: 310-858-3880