Provider Demographics
NPI:1336295955
Name:GOLDENBERG, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:GOLDENBERG
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 1:245 EAST 87TH STREET, APT 10F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128
Mailing Address - Country:US
Mailing Address - Phone:917-209-9940
Mailing Address - Fax:212-987-1197
Practice Address - Street 1:5 E 98TH ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-9065
Practice Address - Fax:212-987-1197
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD66160207N00000X, 207ND0900X
NY250770207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413500800Medicaid
MD89673801OtherCAREFIRST OF MARYLAND
0034OtherCAREFIRST FEP
MD89673801OtherCAREFIRST OF MARYLAND
MDQ731Medicare PIN
NYA400008175Medicare PIN
MD413500800Medicaid