Provider Demographics
NPI:1346393915
Name:GOLDBERG, STEPHEN DANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DANIEL
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 BYRON RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3104
Mailing Address - Country:US
Mailing Address - Phone:407-671-3161
Mailing Address - Fax:
Practice Address - Street 1:460 E ALTAMONTE DR STE 2200
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4602
Practice Address - Country:US
Practice Address - Phone:407-869-8747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0002722363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical