Healthcare Provider Details

I. General information

NPI: 1417479189
Provider Name (Legal Business Name): GOLAN INTEGRATED PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/21/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 S MARYLAND PKWY STE 201
LAS VEGAS NV
89109-6227
US

IV. Provider business mailing address

PO BOX 561564
DENVER CO
80256-1564
US

V. Phone/Fax

Practice location:
  • Phone: 702-396-4993
  • Fax: 702-478-9594
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number7091
License Number StateNV

VIII. Authorized Official

Name: DAVID GOLAN
Title or Position: OWNER
Credential: MD
Phone: 480-213-8448