Provider Demographics
NPI:1346280443
Name:GOLDBERG, STANLEY J (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:J
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 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-876-6953
Practice Address - Street 1:13640 N PLAZA DEL RIO BLVD
Practice Address - Street 2:STE 310
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4846
Practice Address - Country:US
Practice Address - Phone:623-876-3910
Practice Address - Fax:623-876-6953
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11831208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ227159Medicaid
AZ227159Medicaid
AZ020028874Medicare PIN
AZD43973Medicare UPIN
AZZWCKJD59Medicare PIN