Provider Demographics
NPI:1447443320
Name:GOLI, JOHN ISSAC
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ISSAC
Last Name:GOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2642 HORIZON RIDGE PKWY
Mailing Address - Street 2:#A5
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-6480
Mailing Address - Country:US
Mailing Address - Phone:702-553-3273
Mailing Address - Fax:702-795-7463
Practice Address - Street 1:2642 HORIZON RIDGE PKWY
Practice Address - Street 2:#A5
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-6480
Practice Address - Country:US
Practice Address - Phone:702-553-3273
Practice Address - Fax:702-795-7463
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV010C-2007302783335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier