Provider Demographics
NPI:1346311966
Name:GOLDBERG, DAVID A (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 LAFAYETTE RD
Mailing Address - Street 2:STE C
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5679
Mailing Address - Country:US
Mailing Address - Phone:603-431-5600
Mailing Address - Fax:603-431-5610
Practice Address - Street 1:1900 LAFAYETTE RD
Practice Address - Street 2:STE C
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5679
Practice Address - Country:US
Practice Address - Phone:603-431-5600
Practice Address - Fax:603-431-5610
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE8968OtherMEDICARE GROUP #
AA79032OtherHARVARD PILGRIM GROUP #
NH08Y007254NH03OtherANTHEM INDIV #
NH30394988Medicaid
ME098826OtherANTHEM MAINE
ME098826OtherANTHEM INDIV # MAINE
NH30394988Medicaid