Provider Demographics
NPI:1417170432
Name:GOLDENBERG, DAVID TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TODD
Last Name:GOLDENBERG
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:PO BOX 32530
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-2530
Mailing Address - Country:US
Mailing Address - Phone:602-222-2221
Mailing Address - Fax:602-265-5077
Practice Address - Street 1:1101 E MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2709
Practice Address - Country:US
Practice Address - Phone:602-222-2221
Practice Address - Fax:602-266-2044
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089370207W00000X
AZ41482207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436752Medicaid
MI5192486Medicaid
MI38-1946761OtherGRP TAX ID
MI5192486Medicaid