Provider Demographics
NPI:1700263183
Name:JAN PAUL GOLDBERG
Entity Type:Organization
Organization Name:JAN PAUL GOLDBERG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-912-4900
Mailing Address - Street 1:816 ACOMA ST
Mailing Address - Street 2:1113
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4010
Mailing Address - Country:US
Mailing Address - Phone:303-912-4900
Mailing Address - Fax:720-328-9367
Practice Address - Street 1:816 ACOMA ST
Practice Address - Street 2:1113
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4010
Practice Address - Country:US
Practice Address - Phone:303-912-4900
Practice Address - Fax:720-328-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21715261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21715OtherCOLORADO LICENSE