Provider Demographics
NPI:1790763399
Name:GOLDBERG, ROBERT THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THEODORE
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 1:142-10B ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6046
Mailing Address - Country:US
Mailing Address - Phone:718-539-2992
Mailing Address - Fax:718-539-0284
Practice Address - Street 1:142-10B ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6046
Practice Address - Country:US
Practice Address - Phone:718-539-2992
Practice Address - Fax:718-539-0284
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080206207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00113997Medicaid
C05764Medicare UPIN
NY00113997Medicaid