Provider Demographics
NPI:1093713489
Name:GOLDBERGER, JACOB H (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:H
Last Name:GOLDBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:PAYER CONTRACTING AND RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:4571 COLONIAL BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1156
Practice Address - Country:US
Practice Address - Phone:239-274-7600
Practice Address - Fax:239-274-7601
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 35410208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00413910OtherRAILROAD MEDICARE
FL039133600Medicaid
FL1278209OtherWELLCARE
FL7365988OtherCIGNA PROVIDER #
FL95439OtherBCBS FL PROVIDER #
FL039133600Medicaid
D82634Medicare UPIN