Provider Demographics
NPI:1548201791
Name:GOLDBERG, IRWIN MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:MARTIN
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 1:23451 MADISON ST
Mailing Address - Street 2:SUITE #340
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4763
Mailing Address - Country:US
Mailing Address - Phone:310-373-6864
Mailing Address - Fax:310-791-8325
Practice Address - Street 1:23451 MADISON ST
Practice Address - Street 2:SUITE #340
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4763
Practice Address - Country:US
Practice Address - Phone:310-373-6864
Practice Address - Fax:310-791-8325
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31901208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG31901AMedicare ID - Type Unspecified
CAA93535Medicare UPIN