Healthcare Provider Details

I. General information

NPI: 1518376011
Provider Name (Legal Business Name): GOLDEN STATE OTOLARYNGOLOGY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41301 12TH ST W SUITE A
PALMDALE CA
93551-1464
US

IV. Provider business mailing address

41301 12TH ST W SUITE A
PALMDALE CA
93551-1464
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-6277
  • Fax: 661-726-6291
Mailing address:
  • Phone: 661-726-6277
  • Fax: 661-726-6291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA69121
License Number StateCA

VIII. Authorized Official

Name: RUWANTHI CAMPANO
Title or Position: CEO
Credential: MD
Phone: 661-726-6277