Provider Demographics
NPI:1043381262
Name:GOLDBERG, DAVID BRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRETT
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 1:6010 A1A S
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-7018
Mailing Address - Country:US
Mailing Address - Phone:904-461-5080
Mailing Address - Fax:904-217-0840
Practice Address - Street 1:6010 A1A S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-7018
Practice Address - Country:US
Practice Address - Phone:904-461-5080
Practice Address - Fax:904-217-0840
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 32733207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068796100Medicaid
FL95491AMedicare ID - Type Unspecified
FLD78918Medicare UPIN