Provider Demographics
NPI:1598867616
Name:GOLDBERG, KENNETH ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
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 1:541 W MAIN ST STE 150
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3666
Mailing Address - Country:US
Mailing Address - Phone:972-420-8500
Mailing Address - Fax:972-221-6302
Practice Address - Street 1:541 W MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3666
Practice Address - Country:US
Practice Address - Phone:972-420-8500
Practice Address - Fax:972-221-6302
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF 4843208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K9179Medicare PIN
TX8K9182Medicare PIN
85T211Medicare ID - Type Unspecified
TX8K9178Medicare PIN
TX131552508Medicaid
TX131552507Medicaid
B23048Medicare UPIN
TX131552509Medicaid
TX131552505Medicaid