Provider Demographics
NPI:1093852964
Name:GOLDBERG, SUSAN DIAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIAN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2888 EUREKA WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0210
Mailing Address - Country:US
Mailing Address - Phone:530-243-3803
Mailing Address - Fax:530-243-3821
Practice Address - Street 1:2888 EUREKA WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0210
Practice Address - Country:US
Practice Address - Phone:530-243-3803
Practice Address - Fax:530-243-3821
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA49586208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE13727Medicare UPIN