Provider Demographics
NPI:1790946531
Name:GOLDBERG, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
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 1:8425 E 12 MILE RD
Mailing Address - Street 2:SUITE#112
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2738
Mailing Address - Country:US
Mailing Address - Phone:586-574-2692
Mailing Address - Fax:
Practice Address - Street 1:8425 E 12 MILE RD
Practice Address - Street 2:SUITE#112
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2738
Practice Address - Country:US
Practice Address - Phone:586-574-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4074722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology