Provider Demographics
NPI:1306864269
Name:GOLDBERG, GARY IRA (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:IRA
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10420 QUEENS BLVD
Mailing Address - Street 2:SUITE 1W
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3629
Mailing Address - Country:US
Mailing Address - Phone:718-459-7575
Mailing Address - Fax:718-897-8604
Practice Address - Street 1:10420 QUEENS BLVD
Practice Address - Street 2:SUITE 1W
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3629
Practice Address - Country:US
Practice Address - Phone:718-459-7575
Practice Address - Fax:718-897-8604
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY09449Medicare PIN