Provider Demographics
NPI:1740277425
Name:GOLDBERGER, MARK L (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:GOLDBERGER
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25500 MEADOWBROOK RD STE 150
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1880
Mailing Address - Country:US
Mailing Address - Phone:248-784-3667
Mailing Address - Fax:248-869-3982
Practice Address - Street 1:43475 DALCOMA DR STE 150
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3594
Practice Address - Country:US
Practice Address - Phone:248-784-3667
Practice Address - Fax:248-869-3982
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH41595Medicare UPIN
MI0Q26462Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER