Provider Demographics
NPI:1619976669
Name:GOLDENBERG, ILYA G (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:G
Last Name:GOLDENBERG
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 1:2000 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1183
Mailing Address - Country:US
Mailing Address - Phone:614-297-1158
Mailing Address - Fax:614-299-3406
Practice Address - Street 1:2000 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1183
Practice Address - Country:US
Practice Address - Phone:614-297-1158
Practice Address - Fax:614-299-3406
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-081219207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2378896Medicaid
OH7600179OtherUHC
OH7826564OtherAETNA
OH000000259749OtherANTHEM
OH2097512OtherFIRST HEALTH
OH2378896Medicaid
OH7826564OtherAETNA