Provider Demographics
NPI:1093784837
Name:GOLDENBERG, GRIGORIY (MD)
Entity Type:Individual
Prefix:
First Name:GRIGORIY
Middle Name:
Last Name:GOLDENBERG
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 1:20939 23RD AVE APT 2E
Mailing Address - Street 2:BAYSIDE
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1826
Mailing Address - Country:US
Mailing Address - Phone:718-332-5268
Mailing Address - Fax:718-975-0632
Practice Address - Street 1:2792 OCEAN AVE FL 6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4730
Practice Address - Country:US
Practice Address - Phone:718-332-5268
Practice Address - Fax:718-975-0632
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207101207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01862871Medicaid
NY01862871Medicaid
NY2T6352Medicare PIN
NY856391Medicare PIN