Provider Demographics
NPI:1356465793
Name:GOLDBERG, KENNETH W (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
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 1:3590 W 9000 S STE 240
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8864
Mailing Address - Country:US
Mailing Address - Phone:801-569-2384
Mailing Address - Fax:801-569-8643
Practice Address - Street 1:3590 W 9000 S STE 240
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8864
Practice Address - Country:US
Practice Address - Phone:801-569-2384
Practice Address - Fax:801-569-8643
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369085-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG27936Medicare UPIN
UT000012121Medicare ID - Type Unspecified