1275640930 NPI number — DR. MICHAEL SERGIO GOLDBERG MD

Table of content: DR. MICHAEL SERGIO GOLDBERG MD (NPI 1275640930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275640930 NPI number — DR. MICHAEL SERGIO GOLDBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBERG
Provider First Name:
MICHAEL
Provider Middle Name:
SERGIO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLDBERG
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
SERGIO
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1275640930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
191 SAINT JOHNS PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11217-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-928-4079
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N PORTLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11205-2005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-260-7728
Provider Business Practice Location Address Fax Number:
718-260-7517
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  159261 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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