Provider Demographics
NPI:1942729074
Name:GOLDBERG, SOPHIA EVELYN MIMI
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:EVELYN MIMI
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 MACDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-2333
Mailing Address - Country:US
Mailing Address - Phone:510-412-9200
Mailing Address - Fax:
Practice Address - Street 1:4101 MACDONALD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-2333
Practice Address - Country:US
Practice Address - Phone:510-412-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA900141226OtherUNITED HEALTHCARE