Basic Information
| Provider Information | |||||||||
| NPI: | 1972509800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLOD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | IRA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 W. EL CAMINO REAL | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940406203 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15720 WINCHESTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS GATOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950303337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509347000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/25/2006 | ||||||||
| NPIReactivationDate: | 04/06/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G33893 | CA | N | Other Service Providers | Specialist | 207X00000X | G33893 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ02894Z | 01 | CA | BLUE SHIELD | OTHER | 757201035 | 01 | CA | RAILROAD MEDICARE | OTHER |