Provider Demographics
NPI:1710971619
Name:GOLDBERG, PAUL B (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:B
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 1:4641 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1827
Mailing Address - Country:US
Mailing Address - Phone:203-371-6060
Mailing Address - Fax:
Practice Address - Street 1:4641 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1827
Practice Address - Country:US
Practice Address - Phone:203-371-6060
Practice Address - Fax:203-371-1977
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020804207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1208040Medicaid
CT1208040Medicaid
040000149Medicare ID - Type Unspecified