Provider Demographics
NPI:1356365076
Name:GOLDBERG, ANDREW G (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:G
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 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-264-0904
Mailing Address - Fax:703-264-0906
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 301
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-264-0904
Practice Address - Fax:703-264-0906
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA214669OtherANTHEM BLUE CROSS BLUE SH
DC12420001OtherCAREFIRST BLUE CHOICE
VA214669OtherANTHEM BLUE CROSS BLUE SH
00A800R72Medicare ID - Type Unspecified