Provider Demographics
NPI:1578563128
Name:GOLDBERG, DAVID D (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 KETTERING BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1962
Mailing Address - Country:US
Mailing Address - Phone:937-293-2133
Mailing Address - Fax:937-293-2161
Practice Address - Street 1:3033 KETTERING BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1962
Practice Address - Country:US
Practice Address - Phone:937-293-2133
Practice Address - Fax:937-293-2161
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-2116G207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000226414OtherANTHEM
OH0203998Medicaid
A74304Medicare UPIN
OH0379907Medicare PIN
OH0379906Medicare PIN