Healthcare Provider Details

I. General information

NPI: 1427420009
Provider Name (Legal Business Name): GOLDSTAR PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15290 SUMMIT AVE SUITE B
FONTANA CA
92336-0240
US

IV. Provider business mailing address

15290 SUMMIT AVE STE B
FONTANA CA
92336-0240
US

V. Phone/Fax

Practice location:
  • Phone: 909-225-1900
  • Fax:
Mailing address:
  • Phone: 909-225-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberFNP544821
License Number StateCA

VIII. Authorized Official

Name: DR. IRMGARD UNA TACKIE
Title or Position: PHYSICIAN/CEO
Credential: MD
Phone: 909-225-1900