Provider Demographics
NPI:1952580904
Name:GOLDBERG, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
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 1:12264 EL CAMINO REAL STE 303
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3062
Mailing Address - Country:US
Mailing Address - Phone:866-393-9869
Mailing Address - Fax:866-393-9868
Practice Address - Street 1:12264 EL CAMINO REAL STE 303
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130
Practice Address - Country:US
Practice Address - Phone:866-393-9869
Practice Address - Fax:866-393-9868
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0905022084N0400X, 2084P2900X
OH350905022084S0012X, 208VP0000X, 208VP0014X
CAA1128542084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP02046317OtherRR MEDICARE PTAN
CACB298481OtherMEDICARE PTAN
OH2825269Medicaid