Provider Demographics
NPI:1003914102
Name:GOLDBERG, BRYAN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DOUGLAS
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:PO BOX 2699
Mailing Address - Street 2:DEPT 200
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06146-2699
Mailing Address - Country:US
Mailing Address - Phone:086-689-8713
Mailing Address - Fax:
Practice Address - Street 1:41 BREWSTER RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5161
Practice Address - Country:US
Practice Address - Phone:860-585-3433
Practice Address - Fax:860-585-3910
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034419207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F18406Medicare UPIN