Provider Demographics
NPI:1497835342
Name:GOLDBERG, GARY J (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
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 1:9229 LBJ FWY
Mailing Address - Street 2:STE 250
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3405
Mailing Address - Country:US
Mailing Address - Phone:800-346-0747
Mailing Address - Fax:972-739-2638
Practice Address - Street 1:3100 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0436
Practice Address - Country:US
Practice Address - Phone:972-915-3600
Practice Address - Fax:972-915-3636
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5725207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002610Medicaid
NVD12023Medicare UPIN
NVAW724ZMedicare PIN
NVWQBGM06Medicare ID - Type UnspecifiedMEDICARE ID #