Provider Demographics
NPI:1841482601
Name:MARK D GOLDBERG, MD, PC
Entity type:Organization
Organization Name:MARK D GOLDBERG, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-396-3222
Mailing Address - Street 1:5252 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8022
Mailing Address - Country:US
Mailing Address - Phone:480-396-3222
Mailing Address - Fax:480-396-2298
Practice Address - Street 1:5252 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8022
Practice Address - Country:US
Practice Address - Phone:480-396-3222
Practice Address - Fax:480-396-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18592261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ298704Medicaid
AZ348260Medicaid
AZF000274Medicaid
AZG36096Medicare UPIN
AZE23902Medicare UPIN
AZF000274Medicaid
AZE23902Medicare UPIN
AZ348260Medicaid