Provider Demographics
NPI:1184612251
Name:GOLDBERG, NEIL J (DO)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:J
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
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 61773
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1773
Mailing Address - Country:US
Mailing Address - Phone:602-682-6701
Mailing Address - Fax:602-240-6177
Practice Address - Street 1:2632 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1339
Practice Address - Country:US
Practice Address - Phone:602-266-2200
Practice Address - Fax:602-604-5045
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3653207RC0000X
AZ1031207RI0011X
AZ1003207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ560054Medicaid
AZWCSKQOtherSUN HEALTH GROUP #
AZAZ0886080OtherBCBS #
AZP00304261OtherRAILROAD MEDICARE
AZ560054Medicaid
AZZ109508Medicare PIN