Provider Demographics
NPI:1053538694
Name:GOLDSTEIN, THEODORE B (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:B
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S SPALDING DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-1800
Mailing Address - Country:US
Mailing Address - Phone:310-860-3450
Mailing Address - Fax:
Practice Address - Street 1:120 S SPALDING DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1800
Practice Address - Country:US
Practice Address - Phone:310-860-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG13277OtherSTATE LICENSE
CAG13277OtherSTATE LICENSE