Provider Demographics
NPI:1962671669
Name:LEON M. GOLDBERG, M.D., MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LEON M. GOLDBERG, M.D., MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-771-0220
Mailing Address - Street 1:705 W LA VETA AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4402
Mailing Address - Country:US
Mailing Address - Phone:714-771-0220
Mailing Address - Fax:714-771-0288
Practice Address - Street 1:705 W LA VETA AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4402
Practice Address - Country:US
Practice Address - Phone:714-771-0220
Practice Address - Fax:714-771-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13531208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G13531Medicare PIN
A90260Medicare UPIN