Provider Demographics
NPI: | 1619061942 |
---|---|
Name: | GOLDBERG, JOSHUA M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOSHUA |
Middle Name: | M |
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: | 2501 N ORANGE AVE STE 401 |
Mailing Address - Street 2: | |
Mailing Address - City: | ORLANDO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32804-4644 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 601 E ROLLINS ST |
Practice Address - Street 2: | |
Practice Address - City: | ORLANDO |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32803-1248 |
Practice Address - Country: | US |
Practice Address - Phone: | 407-303-7283 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-03 |
Last Update Date: | 2023-04-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | MD.204457 | 2086S0102X |
FL | ME133602 | 2086S0102X |
CO | 42813 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2086S0102X | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MS | 02975556 | Medicaid | |
CO | 69074828 | Medicaid | |
LA | 2141139 | Medicaid | |
LA | 4Q0737061 | Medicare PIN | |
CO | 69074828 | Medicaid |