Provider Demographics
NPI:1114914389
Name:GOLDBERG, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GOLDBERG
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 1:741 NORTHFIELD AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1174
Mailing Address - Country:US
Mailing Address - Phone:973-467-1544
Mailing Address - Fax:973-467-9586
Practice Address - Street 1:741 NORTHFIELD AVE
Practice Address - Street 2:STE 205
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1174
Practice Address - Country:US
Practice Address - Phone:973-467-1544
Practice Address - Fax:973-467-9586
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ50551207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4580303Medicaid
81670OtherAMERIGROUP
ES474OtherOXFORD
4340667OtherAETNA
1K9390OtherHEALTHNET
52B941OtherWELLCHOICE
6312229006OtherCIGNA
010000352200OtherAMERICHOICE
0503191000OtherAMERIHEALTH
5710571OtherGHI
E84256Medicare UPIN
NJ4580303Medicaid