Provider Demographics
NPI:1821064684
Name:GOLDBERG, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21840 NORMANDIE AVE
Mailing Address - Street 2:STE. 700
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2047
Mailing Address - Country:US
Mailing Address - Phone:310-222-5101
Mailing Address - Fax:310-320-5463
Practice Address - Street 1:21840 NORMANDIE AVE
Practice Address - Street 2:STE. 700
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2047
Practice Address - Country:US
Practice Address - Phone:310-222-5101
Practice Address - Fax:310-320-5463
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG206992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G206990Medicaid
CADA6447OtherRAILROAD MEDICARE
CAM050376OtherGROUP
CAWG20699EMedicare PIN
CADA6447OtherRAILROAD MEDICARE
CAA41030Medicare UPIN