Provider Demographics
NPI:1760559116
Name:GOLDBERG, GLENN I (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:I
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:31852 COAST HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-6764
Practice Address - Country:US
Practice Address - Phone:949-499-1389
Practice Address - Fax:949-499-5689
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A5649207ND0101X, 207ND0900X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A5649AMedicare ID - Type Unspecified
CAE32312Medicare UPIN