Provider Demographics
NPI:1144566985
Name:KENNETH A GOLDBERG MD PA
Entity Type:Organization
Organization Name:KENNETH A GOLDBERG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONJIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-420-8500
Mailing Address - Street 1:541 W MAIN ST
Mailing Address - Street 2:SUITE150
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3628
Mailing Address - Country:US
Mailing Address - Phone:972-420-8500
Mailing Address - Fax:972-221-6302
Practice Address - Street 1:541 W MAIN ST
Practice Address - Street 2:SUITE150
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3628
Practice Address - Country:US
Practice Address - Phone:972-420-8500
Practice Address - Fax:972-221-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4843208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty