Provider Demographics
NPI:1801063789
Name:GOLDBERG, ALLA (MD)
Entity type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALLA
Other - Middle Name:
Other - Last Name:KUKUYEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6400 FANNIN ST
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1521
Mailing Address - Country:US
Mailing Address - Phone:713-559-5200
Mailing Address - Fax:713-795-0733
Practice Address - Street 1:6000 HILLANDALE DR STE 130
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4860
Practice Address - Country:US
Practice Address - Phone:770-981-9010
Practice Address - Fax:770-593-3461
Is Sole Proprietor?:No
Enumeration Date:2008-05-10
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85747207W00000X
TXP2884207WX0107X, 207W00000X, 207WX0108X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083251101Medicaid
TX363919YQQ8Medicare PIN