Basic Information
Provider Information | |||||||||
NPI: | 1255396594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOETZL | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1635 DIVISADERO STREET, SUITE 625, BOX 1821 | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941430001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4154764029 | ||||||||
FaxNumber: | 4154764150 | ||||||||
Practice Location | |||||||||
Address1: | 400 PARNASSUS AVE | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941432202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4153532725 | ||||||||
FaxNumber: | 4153532568 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G47295 | CA | X |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0201X | G47295 | CA | X |   | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RR0500X | G47295 | CA | X |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 0G4729500 | 05 | CA |   | MEDICAID |