Provider Demographics
NPI:1609895218
Name:GOLDBERG, LEE RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:RANDALL
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:PO BOX 64086
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728-4086
Mailing Address - Country:US
Mailing Address - Phone:520-323-7277
Mailing Address - Fax:320-881-1968
Practice Address - Street 1:3955 E FORT LOWELL RD
Practice Address - Street 2:SUITE 113
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1041
Practice Address - Country:US
Practice Address - Phone:520-323-7277
Practice Address - Fax:520-881-1968
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31261207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ119329OtherPTAN
AZ79077601Medicaid
AZG93370Medicare UPIN
AZ79077601Medicaid