Provider Demographics
NPI:1013995034
Name:GOLDBERG, GARY S (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
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 8674
Mailing Address - Street 2:1230 E MAIN ST MANKATO CLINIC LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIERE DR
Practice Address - Street 2:MANKATO CLINIC@ WICKERSHAM CAMPUS
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43508208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN140754OtherUCARE
340019399OtherRR MEDICARE
MNHP34028OtherHEALTH PARTNERS
MN1808800OtherAMERICAS PPO
MN1900310OtherMEDICA
IA0568394OtherMEDICAID
MN392183200Medicaid
MN47D36GOOtherBCBS
MNNA2951028013OtherPREFFERED ONE
340019399OtherRR MEDICARE
MN47D36GOOtherBCBS