Provider Demographics
NPI:1740298538
Name:GOLDBERG, STANLEY MORTON (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:MORTON
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 1:1055 WESTGATE DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1065
Mailing Address - Country:US
Mailing Address - Phone:651-312-1520
Mailing Address - Fax:651-312-1593
Practice Address - Street 1:6363 FRANCE AVE S
Practice Address - Street 2:SUITE 212
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2129
Practice Address - Country:US
Practice Address - Phone:651-312-1700
Practice Address - Fax:952-920-4148
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13851208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94589Medicare UPIN