Provider Demographics
NPI:1376616730
Name:GOLDBERG, FRED (DPM)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 ROUTE 59
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-5204
Mailing Address - Country:US
Mailing Address - Phone:845-357-4433
Mailing Address - Fax:845-357-0518
Practice Address - Street 1:222 ROUTE 59
Practice Address - Street 2:SUITE 208
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-5204
Practice Address - Country:US
Practice Address - Phone:845-357-4433
Practice Address - Fax:845-357-0518
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN2584213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BG9498177OtherDEA
NYP2925Medicare ID - Type Unspecified
T50814Medicare UPIN