Provider Demographics
NPI:1356463434
Name:GOLDBERG, ILAN PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:ILAN
Middle Name:PHILIP
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 1:12 OLIVER RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4136
Mailing Address - Country:US
Mailing Address - Phone:781-990-8349
Mailing Address - Fax:
Practice Address - Street 1:9 MERIAM ST STE 22
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5312
Practice Address - Country:US
Practice Address - Phone:617-667-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2344002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry