Healthcare Provider Details

I. General information

NPI: 1881963775
Provider Name (Legal Business Name): HARRIS S GOLDMAN M D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BALBOA BLVD
ENCINO CA
91316-1502
US

IV. Provider business mailing address

5400 BALBOA BLVD
ENCINO CA
91316-1502
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-2001
  • Fax: 818-788-2021
Mailing address:
  • Phone: 818-788-2001
  • Fax: 818-788-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberG13314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: