Provider Demographics
NPI:1205820941
Name:GOLDBERG, LARRY PHILIP (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:PHILIP
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ENDICOTT ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3623
Mailing Address - Country:US
Mailing Address - Phone:978-882-6868
Mailing Address - Fax:978-882-6855
Practice Address - Street 1:104 ENDICOTT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3623
Practice Address - Country:US
Practice Address - Phone:978-882-6868
Practice Address - Fax:978-882-6855
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49380208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3023125Medicaid
D17054Medicare PIN
MA3023125Medicaid