Provider Demographics
NPI:1477654291
Name:GOLDBERG, JAY STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:STEPHEN
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 1:430 CLAREMONT CT
Mailing Address - Street 2:SUITE 213
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1770
Mailing Address - Country:US
Mailing Address - Phone:804-520-2626
Mailing Address - Fax:804-520-0626
Practice Address - Street 1:430 CLAREMONT CT
Practice Address - Street 2:SUITE 213
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1770
Practice Address - Country:US
Practice Address - Phone:804-520-2626
Practice Address - Fax:804-520-0626
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021527208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477654291Medicaid
VA1477654291OtherBCBS
VA1477654291OtherBCBS