Provider Demographics
NPI:1881656395
Name:GOLDBERG, RICHARD MELVIN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MELVIN
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:PO BOX 80116
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8116
Mailing Address - Country:US
Mailing Address - Phone:800-749-4560
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:501 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4809
Practice Address - Country:US
Practice Address - Phone:818-843-5111
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19165208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G191650Medicaid
00G191650OtherBLUE SHIELD
G19165OtherBLUE CROSS
WG19165AMedicare ID - Type Unspecified
A40553Medicare UPIN