Provider Demographics
NPI:1174794408
Name:GOLDEN STATE OTOLARYNGOLOGY MEDICAL
Entity type:Organization
Organization Name:GOLDEN STATE OTOLARYNGOLOGY MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUWANTHI
Authorized Official - Middle Name:S
Authorized Official - Last Name:CAMPANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-726-6277
Mailing Address - Street 1:PO BOX 6558
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-6558
Mailing Address - Country:US
Mailing Address - Phone:661-726-6277
Mailing Address - Fax:661-726-6291
Practice Address - Street 1:301 DRUMMOND AVE
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3187
Practice Address - Country:US
Practice Address - Phone:760-371-7329
Practice Address - Fax:661-726-6291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64933ZOtherBLUE SHIELD
CAZZZ64933ZOtherBLUE SHIELD
CAH58655Medicare UPIN