Provider Demographics
NPI:1346353059
Name:GOLDBERG, HEIDI
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15809 PENNINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1582
Mailing Address - Country:US
Mailing Address - Phone:813-960-7841
Mailing Address - Fax:
Practice Address - Street 1:9555 SEMINOLE BLVD
Practice Address - Street 2:STE 201
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2562
Practice Address - Country:US
Practice Address - Phone:727-393-6881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053509207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE58381Medicare UPIN
FL09647Medicare ID - Type Unspecified