Provider Demographics
NPI:1275640930
Name:GOLDBERG, MICHAEL SERGIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SERGIO
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:SERGIO
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:191 SAINT JOHNS PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3405
Mailing Address - Country:US
Mailing Address - Phone:718-928-4079
Mailing Address - Fax:
Practice Address - Street 1:100 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-2005
Practice Address - Country:US
Practice Address - Phone:718-260-7728
Practice Address - Fax:718-260-7517
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1592612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY42F401Medicare ID - Type Unspecified