Provider Demographics
NPI:1497195580
Name:GOLAN INTEGRATED PHYSICAL MEDICINE
Entity type:Organization
Organization Name:GOLAN INTEGRATED PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-463-9726
Mailing Address - Street 1:PO BOX 561564
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-1564
Mailing Address - Country:US
Mailing Address - Phone:702-202-1850
Mailing Address - Fax:
Practice Address - Street 1:6592 N DECATUR BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-1037
Practice Address - Country:US
Practice Address - Phone:702-478-9594
Practice Address - Fax:702-478-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6983960001OtherPTAN
NV6983960001OtherPTAN
NV6983960001Medicare NSC