Provider Demographics
NPI:1336229178
Name:GOLDBERG, JEFFREY E (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:E
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 1:4245 JOHNS CREEK PKWY.
Mailing Address - Street 2:SUITE D
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:770-495-3820
Mailing Address - Fax:770-495-3825
Practice Address - Street 1:4245 JOHNS CREEK PKWY.
Practice Address - Street 2:SUITE D
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024
Practice Address - Country:US
Practice Address - Phone:770-495-3820
Practice Address - Fax:770-495-3825
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036754207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F53752Medicare UPIN