Provider Demographics
NPI:1558715375
Name:GOLDBERG, ILIYA (MD)
Entity Type:Individual
Prefix:
First Name:ILIYA
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 1:401 E HIGHLAND AVE STE 351
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3830
Mailing Address - Country:US
Mailing Address - Phone:909-475-8611
Mailing Address - Fax:909-475-2566
Practice Address - Street 1:401 E HIGHLAND AVE STE 351
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3830
Practice Address - Country:US
Practice Address - Phone:909-475-8611
Practice Address - Fax:909-475-2566
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA170915208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program