Provider Demographics
NPI:1235157249
Name:GOLDBERG, JACOB (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6340
Mailing Address - Country:US
Mailing Address - Phone:508-620-1919
Mailing Address - Fax:508-820-3093
Practice Address - Street 1:359 UNION AVE
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6340
Practice Address - Country:US
Practice Address - Phone:508-620-1919
Practice Address - Fax:508-820-3093
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA328632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3023621Medicaid
MAM12188Medicare ID - Type Unspecified
MAB76933Medicare UPIN