MEDICARE: GOLDSTAR PEDIATRICS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	FNP544821	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427420009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDSTAR PEDIATRICS PC

Provider Business Mailing Address
First Line	:	15290 SUMMIT AVE STE B
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-0240
Country	:	US
Telephone Number	:	909-225-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	15290 SUMMIT AVE
Second Line	:	SUITE B
City	:	FONTANA
State	:	CA
Zip	:	92336-0240
Country	:	US
Telephone Number	:	909-225-1900
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/CEO
Name	:	DR. IRMGARD UNA TACKIE
Credential	:	MD
Telephone Number	:	909-225-1900

Provider Enumeration Date	:	10/22/2015
Last Update Date	:	12/23/2021

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