Provider Demographics
NPI:1760488993
Name:GOLDBERG, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
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:PO BOX 8686
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45208-0686
Mailing Address - Country:US
Mailing Address - Phone:513-686-5444
Mailing Address - Fax:513-686-5443
Practice Address - Street 1:4777 E GALBRAITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2725
Practice Address - Country:US
Practice Address - Phone:513-686-5444
Practice Address - Fax:513-686-5443
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0322-15207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0243632Medicaid
OHD31309Medicare UPIN
OH0243632Medicaid