Provider Demographics
NPI:1528036563
Name:GOLDBERG, JOHN MAYER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MAYER
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 1:1601 NW 12TH AVE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-243-6275
Mailing Address - Fax:305-243-3816
Practice Address - Street 1:1601 NW 12TH AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-6275
Practice Address - Fax:305-243-3816
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1013702080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2810816-00Medicaid
213948OtherTUFTS
AA39038OtherHPHC DFCI ONLY
MA2018161Medicaid
J26754OtherMASSACHUSETTS BCBS
A38379Medicare ID - Type Unspecified
FL2810816-00Medicaid
FLAK440ZMedicare PIN