Provider Demographics
NPI:1598856585
Name:GOLDBERG, KENNETH CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2736 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5718
Mailing Address - Country:US
Mailing Address - Phone:919-490-5320
Mailing Address - Fax:
Practice Address - Street 1:508 FULTON ST
Practice Address - Street 2:BOX 11C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3875
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:919-416-5880
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-01539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG69126Medicare UPIN