Provider Demographics
NPI:1336107200
Name:GOLDBERG, CHARLES BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BARRY
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 1:7215 SE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5803
Mailing Address - Country:US
Mailing Address - Phone:503-954-2187
Mailing Address - Fax:503-238-7025
Practice Address - Street 1:7215 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-954-2187
Practice Address - Fax:503-238-7025
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268490Medicaid
OR115294Medicare ID - Type Unspecified
OR268490Medicaid