Provider Demographics
NPI:1790764736
Name:GOLDBERG, GARY D (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
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 1:535 PLANDOME RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1961
Mailing Address - Country:US
Mailing Address - Phone:516-627-6188
Mailing Address - Fax:516-627-9397
Practice Address - Street 1:535 PLANDOME RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-1961
Practice Address - Country:US
Practice Address - Phone:516-627-6188
Practice Address - Fax:516-627-9397
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181762208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG01662Medicare UPIN
NY46L821Medicare ID - Type Unspecified