Provider Demographics
NPI:1669670519
Name:GOLDBERG, JACOB R (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:914-242-1516
Practice Address - Street 1:97 W PARKWAY
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1647
Practice Address - Country:US
Practice Address - Phone:973-831-5000
Practice Address - Fax:973-831-5432
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY244749207R00000X, 208M00000X
NJ25MA08706500208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0667910001OtherDME
NYP00421811OtherMEDICARE RAILROAD
NY02888411Medicaid
NY2RR521Medicare PIN
NY2RR5206761Medicare PIN