Provider Demographics
NPI:1457669673
Name:GOLDBERG, KENNETH CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
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 1:407 NE 12TH AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-280-0880
Mailing Address - Fax:503-232-7440
Practice Address - Street 1:407 NE 12TH AVE
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-280-0880
Practice Address - Fax:503-232-7440
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD160862083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine