Provider Demographics
NPI:1164443958
Name:GOLDBERG, CHARLES S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
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 1:127 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042
Mailing Address - Country:US
Mailing Address - Phone:973-233-9559
Mailing Address - Fax:973-233-9660
Practice Address - Street 1:127 PINE STREET
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-233-9559
Practice Address - Fax:973-233-9660
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA041455207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6606504Medicaid
NJ551565YQ5Medicare PIN
NJ6606504Medicaid