Healthcare Provider Details

I. General information

NPI: 1356874929
Provider Name (Legal Business Name): GAN GOLSHTEYN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6145 N THESTA ST
FRESNO CA
93710-5266
US

IV. Provider business mailing address

861 TUSCANY CT
LEMOORE CA
93245-9339
US

V. Phone/Fax

Practice location:
  • Phone: 559-436-4820
  • Fax:
Mailing address:
  • Phone: 954-512-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00354700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5760
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: