Provider Demographics
NPI:1477549749
Name:GOLDABER, KENNETH GORDON (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GORDON
Last Name:GOLDABER
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 1:515 W MAYFIELD RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2083
Mailing Address - Country:US
Mailing Address - Phone:817-467-1010
Mailing Address - Fax:817-419-2626
Practice Address - Street 1:515 W MAYFIELD RD
Practice Address - Street 2:SUITE 304
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2083
Practice Address - Country:US
Practice Address - Phone:817-467-1010
Practice Address - Fax:817-419-2626
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3815207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161496801Medicaid
TX27KHOtherBLUE CROSS BLUE SHIELD
TX161496801Medicare ID - Type Unspecified
TX27KHOtherBLUE CROSS BLUE SHIELD