MEDICARE: MICHAEL G GOLDSTEIN MD INC

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	208D00000X	General Practice Physician	G20440	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G20440	OTHER	CA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1568650604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL G GOLDSTEIN MD INC

Provider Business Mailing Address
First Line	:	231 W VERNON AVE
Second Line	:	204
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2700
Country	:	US
Telephone Number	:	323-521-1544
Fax Number	:	323-521-1546

Provider Business Practice Location Address
First Line	:	231 W VERNON AVE
Second Line	:	204
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2700
Country	:	US
Telephone Number	:	323-521-1544
Fax Number	:	323-521-1546

Authorized Official
Title or Position	:	CEO/PRES
Name	:	DR. MICHAEL G GOLDSTEIN
Credential	:	M.D.
Telephone Number	:	323-521-1544

Provider Enumeration Date	:	10/12/2007
Last Update Date	:	10/12/2007

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