Provider Demographics
NPI:1568565190
Name:GOLDBERG, BRUCE A (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
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 1:85 CONSTITUTION LN
Mailing Address - Street 2:SUITE 200C
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3694
Mailing Address - Country:US
Mailing Address - Phone:978-750-3670
Mailing Address - Fax:978-750-3606
Practice Address - Street 1:85 CONSTITUTION LANE
Practice Address - Street 2:STE 200C LIBERTY TREE PARK
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923
Practice Address - Country:US
Practice Address - Phone:978-750-3670
Practice Address - Fax:978-750-3606
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA465042084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3015149Medicaid
MAV02758OtherBLUE CROSS
MA046504OtherTUFTS
MAV02758Medicare PIN
MAV02758OtherBLUE CROSS