Provider Demographics
NPI:1336190552
Name:GOLDENBERG, MARAT (MD)
Entity Type:Individual
Prefix:
First Name:MARAT
Middle Name:
Last Name:GOLDENBERG
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 1524
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1524
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901
Practice Address - Country:US
Practice Address - Phone:706-774-7263
Practice Address - Fax:706-774-7230
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0681712086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126148BMedicaid
GA003126148AMedicaid
GA003126148AMedicaid