Provider Demographics
NPI:1033142112
Name:GOLDBERG, GRIGORY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GRIGORY
Middle Name:R
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 1:1200 EAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-7631
Mailing Address - Country:US
Mailing Address - Phone:732-660-6200
Mailing Address - Fax:
Practice Address - Street 1:1200 EAGLE AVE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-7631
Practice Address - Country:US
Practice Address - Phone:732-660-6200
Practice Address - Fax:732-660-6201
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-089481207XS0117X
KY39810207XS0117X
NJ25MA08514200207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000526432OtherANTHEM
KY000000485763OtherANTHEM
OH165869OtherNATIONWIDE
KY000000485763OtherANTHEM
OHGO4210791Medicare PIN