Provider Demographics
NPI:1083790174
Name:GOLDBERG, JACK B (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4801 S CONGRESS AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4746
Mailing Address - Country:US
Mailing Address - Phone:561-434-1469
Mailing Address - Fax:561-434-1197
Practice Address - Street 1:4801 S CONGRESS AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4746
Practice Address - Country:US
Practice Address - Phone:561-434-1469
Practice Address - Fax:561-434-1197
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL0S4026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD60616Medicare UPIN