Provider Demographics
NPI:1093913642
Name:GOLDBERG, ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9324 QUEENS BLVD
Mailing Address - Street 2:STE 1G
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1130
Mailing Address - Country:US
Mailing Address - Phone:718-850-6345
Mailing Address - Fax:718-559-4895
Practice Address - Street 1:13876 QUEENS BLVD
Practice Address - Street 2:1ST. FLOOR
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-2930
Practice Address - Country:US
Practice Address - Phone:718-850-6345
Practice Address - Fax:718-559-4895
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03133740Medicaid
NYG85785Medicare UPIN
NYG400024359Medicare PIN