Provider Demographics
NPI:1497826440
Name:GOLDBERG, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
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 1:1043 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1237
Mailing Address - Country:US
Mailing Address - Phone:847-414-5804
Mailing Address - Fax:847-316-3307
Practice Address - Street 1:1043 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1237
Practice Address - Country:US
Practice Address - Phone:847-414-5804
Practice Address - Fax:847-316-3307
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45433Medicare UPIN
ILK05398Medicare ID - Type Unspecified