Provider Demographics
NPI:1093723983
Name:GOLDBERG, JEFFREY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4 FARM SPRINGS ROAD
Mailing Address - Street 2:PROHEALTH PHYSICIANS INC
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2573
Mailing Address - Country:US
Mailing Address - Phone:860-284-5200
Mailing Address - Fax:860-284-5333
Practice Address - Street 1:25 COLLINS ROAD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-589-8882
Practice Address - Fax:860-585-8898
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT036141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G54614Medicare UPIN