Provider Demographics
NPI:1780872671
Name:GOLDBAN, WALLACE FRANKLIN (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:FRANKLIN
Last Name:GOLDBAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1180 N INDIAN CANYON DR STE W100
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4834
Mailing Address - Country:US
Mailing Address - Phone:760-320-8497
Mailing Address - Fax:760-320-5444
Practice Address - Street 1:1180 N INDIAN CANYON DR STE W100
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4834
Practice Address - Country:US
Practice Address - Phone:760-320-8497
Practice Address - Fax:760-320-5444
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG077969207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G65381Medicare UPIN
CACO825ZMedicare PIN