Provider Demographics
NPI:1144530007
Name:MYTIEN GOLDBERG MD PC
Entity type:Organization
Organization Name:MYTIEN GOLDBERG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYTIEN
Authorized Official - Middle Name:THI
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-618-9922
Mailing Address - Street 1:2808 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-3808
Mailing Address - Country:US
Mailing Address - Phone:310-618-9922
Mailing Address - Fax:310-933-0978
Practice Address - Street 1:2808 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-3808
Practice Address - Country:US
Practice Address - Phone:310-618-9922
Practice Address - Fax:310-933-0978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA806762082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376707711OtherPERSONAL PROVIDER NPI NUMBER