Healthcare Provider Details

I. General information

NPI: 1144530007
Provider Name (Legal Business Name): MYTIEN GOLDBERG MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 COLUMBIA ST
TORRANCE CA
90503-3808
US

IV. Provider business mailing address

2808 COLUMBIA ST
TORRANCE CA
90503-3808
US

V. Phone/Fax

Practice location:
  • Phone: 310-618-9922
  • Fax: 310-933-0978
Mailing address:
  • Phone: 310-618-9922
  • Fax: 310-933-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberA80676
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA80676
License Number StateCA

VIII. Authorized Official

Name: DR. MYTIEN THI GOLDBERG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-618-9922