Provider Demographics
NPI:1700175585
Name:GOLDENBERG, LARRY EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:EDWARD
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 1:4302 ALTON RD STE 940
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2890
Mailing Address - Country:US
Mailing Address - Phone:305-674-2655
Mailing Address - Fax:
Practice Address - Street 1:4302 ALTON RD STE 940
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2890
Practice Address - Country:US
Practice Address - Phone:305-674-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN108333207V00000X
FL148834207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2147757Medicaid