Provider Demographics
NPI:1801837141
Name:GOLDBERG, MARCEL ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCEL
Middle Name:ALEXANDER
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 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6400
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:3025 WEST CHERRY LANE
Practice Address - Street 2:SUITE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8531
Practice Address - Country:US
Practice Address - Phone:208-302-6400
Practice Address - Fax:208-302-6455
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54953207Q00000X
IDM-10788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A549530OtherBLUE SHIELD PIN
CAWA54953CMedicare ID - Type UnspecifiedMEDICARE PPIN
CA00A549530OtherBLUE SHIELD PIN