Provider Demographics
NPI:1164463337
Name:GOLDBERG, DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 OFFICE PARK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35223-3409
Mailing Address - Country:US
Mailing Address - Phone:205-380-6304
Mailing Address - Fax:205-802-5371
Practice Address - Street 1:400 OFFICE PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35223-3409
Practice Address - Country:US
Practice Address - Phone:205-380-6304
Practice Address - Fax:205-802-5371
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18635103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP76800Medicare UPIN
CACP18635Medicare ID - Type Unspecified