Provider Demographics
NPI:1629066519
Name:GOLDBERG, MARLYN F (MD)
Entity Type:Individual
Prefix:
First Name:MARLYN
Middle Name:F
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 N ADDISON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2821
Mailing Address - Country:US
Mailing Address - Phone:630-833-9621
Mailing Address - Fax:630-833-9465
Practice Address - Street 1:152 N ADDISON AVE STE 100
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2821
Practice Address - Country:US
Practice Address - Phone:630-833-9621
Practice Address - Fax:630-833-9465
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096240207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088212OtherLICENSE NUMBER
IL05626127OtherBLUE CROSS BLUE SHIELD
IL0360962402Medicaid
ILDA3012OtherRAILROAD GROUP NUMBER
ILP00048835OtherRAILROAD MEDICARE
ILK20276Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #
IL0360962402Medicaid
ILDA3012OtherRAILROAD GROUP NUMBER
IL214343002Medicare PIN