Provider Demographics
NPI:1356319388
Name:GOLDBERG, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2501E SOUTHERN AVE
Mailing Address - Street 2:STE 22
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282
Mailing Address - Country:US
Mailing Address - Phone:480-838-1111
Mailing Address - Fax:480-838-3476
Practice Address - Street 1:2501E SOUTHERN AVE
Practice Address - Street 2:STE 22
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-838-1111
Practice Address - Fax:480-838-3476
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ31151207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ792673OtherAHCCCS
74682Medicare ID - Type Unspecified
G97810Medicare UPIN