Provider Demographics
NPI:1477595239
Name:GOLDENBERG, BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:15200 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3085
Practice Address - Country:US
Practice Address - Phone:228-575-7022
Practice Address - Fax:228-575-7097
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070390A2080N0001X
WI6742080N0001X
LA3296092080N0001X
IL0360748812080N0001X
MS283222080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1J4304Medicaid
MS1L7105Medicaid
IL036074881Medicaid
IN01070390AOtherIN STATE LICENSE
WI100098179Medicaid
IN01070390BOtherCSR
IN000001071268OtherANTHEM PIN
IN000001071268OtherANTHEM PIN