Provider Demographics
NPI:1114931599
Name:GOLDBERG, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
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 1:6250 KIPPS COLONY CT APT 304
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3983
Mailing Address - Country:US
Mailing Address - Phone:727-343-3004
Mailing Address - Fax:727-343-9521
Practice Address - Street 1:6950 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1210
Practice Address - Country:US
Practice Address - Phone:727-343-3004
Practice Address - Fax:727-343-9521
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMD0035408207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066311500Medicaid
FL62354Medicare ID - Type Unspecified
FL066311500Medicaid