Healthcare Provider Details

I. General information

NPI: 1962971788
Provider Name (Legal Business Name): PHILIP GOLDMAN BOEKELHEIDE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E CESAR E CHAVEZ AVE STE 2500
LOS ANGELES CA
90033-2434
US

IV. Provider business mailing address

4640 ADMIRALTY WAY STE 718
MARINA DEL REY CA
90292-6634
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-6731
  • Fax:
Mailing address:
  • Phone: 310-823-4444
  • Fax: 310-363-7085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: