Basic Information
Provider Information | |||||||||
NPI: | 1982804340 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDEN | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D, PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11025 RCA CENTER DR STE 301 | ||||||||
Address2: |   | ||||||||
City: | PALM BEACH GARDENS | ||||||||
State: | FL | ||||||||
PostalCode: | 334104269 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5613833820 | ||||||||
FaxNumber: | 8553692450 | ||||||||
Practice Location | |||||||||
Address1: | 7455 W WASHINGTON AVE STE 301 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 89128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8775625227 | ||||||||
FaxNumber: | 7029389954 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2007 | ||||||||
LastUpdateDate: | 06/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 232375 | MA | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 14798 | 01 | NV | MEDICAL LICENSE | OTHER |