Provider Demographics
NPI:1225141971
Name:GOLDBERG, JAY W (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:W
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:P.O. BOX 10609
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-0609
Mailing Address - Country:US
Mailing Address - Phone:877-818-6100
Mailing Address - Fax:
Practice Address - Street 1:347 ANDRIEUX STREET
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6811
Practice Address - Country:US
Practice Address - Phone:707-935-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66617207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666170Medicaid
CA00A666173Medicare PIN
CA00A666170Medicaid
CA00A666171Medicare PIN
CA00A666174Medicare PIN