Provider Demographics
NPI:1003809096
Name:GOLDBERG, ROBERT PAUL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PAUL
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-2340
Mailing Address - Country:US
Mailing Address - Phone:860-739-4431
Mailing Address - Fax:860-739-9461
Practice Address - Street 1:22 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-2340
Practice Address - Country:US
Practice Address - Phone:860-739-4431
Practice Address - Fax:860-739-9461
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT28990207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010028990CT01OtherBC/BS
CT1289900Medicaid
CT030056OtherHEALTHNET
CT110023443Medicare PIN
CT010028990CT01OtherBC/BS
CT1289900Medicaid