Provider Demographics
NPI:1720157506
Name:GOLDBERG, STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
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 1:100 CHESTER PL
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3634
Mailing Address - Country:US
Mailing Address - Phone:201-871-9138
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:GI ENDOSCOPY, BUILDING ONE, 2-SOUTH
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1138
Practice Address - Country:US
Practice Address - Phone:718-918-5653
Practice Address - Fax:718-918-5649
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181178207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01404902Medicaid