Provider Demographics
NPI:1790706588
Name:GOLDBERG, MELVYN (MD)
Entity Type:Individual
Prefix:
First Name:MELVYN
Middle Name:
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 1:8 HUNTINGDON PIKE FL 3
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:PA
Mailing Address - Zip Code:19046-4338
Mailing Address - Country:US
Mailing Address - Phone:215-214-1405
Mailing Address - Fax:215-214-1023
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-214-1023
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049107L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF54377Medicare UPIN