Provider Demographics
NPI:1093106015
Name:GOLDBERG, MARC DAVID (PT)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:DAVID
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 108TH ST APT 9D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2927
Mailing Address - Country:US
Mailing Address - Phone:917-699-9707
Mailing Address - Fax:
Practice Address - Street 1:255 W 108TH ST APT 9D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2927
Practice Address - Country:US
Practice Address - Phone:917-699-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024642-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ14J31Medicare UPIN