=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790723351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S. MYRON GOLDSTEIN MD FACS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 10/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 N TUSTIN AVE SUITE B
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-273-7300
-----------------------------------------------------
Fax | 714-664-0225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 N TUSTIN AVE SUITE B
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-273-7300
-----------------------------------------------------
Fax | 714-664-0225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHEN MYRON GOLDSTEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-995-0893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G26456
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------