Provider Demographics
NPI:1659303808
Name:GOLDBERG, HOWARD C (MD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:C
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 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:600 PROFESSIONAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7651
Practice Address - Country:US
Practice Address - Phone:770-963-8444
Practice Address - Fax:770-963-2261
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031746174400000X
GA31746208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE79138Medicare UPIN
GA34BDBCTMedicare ID - Type Unspecified