Provider Demographics
NPI:1326338849
Name:GOLDBERG, DEBORAH (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:630-624-1468
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:630-624-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036152013207R00000X, 208M00000X
MO2015009594207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1326338849Medicaid
MOP01507980OtherRAILROAD MEDICARE
MOP01507711OtherRAILROAD MEDICARE
MOP01507980OtherRAILROAD MEDICARE
MO1326338849Medicaid
MO501570071Medicare PIN