Provider Demographics
NPI:1154329936
Name:GOLDBERG, RANDY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:ALLEN
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 1:100 WOODS RD
Mailing Address - Street 2:TCC D376
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1530
Mailing Address - Country:US
Mailing Address - Phone:914-493-6616
Mailing Address - Fax:914-493-5827
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:TCC D376
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-6616
Practice Address - Fax:914-493-5827
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216875207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0050202Medicaid
NY60-216875OtherSTATE LICENSE
NY60-216875OtherSTATE LICENSE
NY60-216875OtherSTATE LICENSE
NJ0050202Medicaid
NJ0050202Medicaid
BG6766630OtherDEA
NJ087631Medicare PIN