Provider Demographics
NPI:1902256530
Name:GOLDBERG, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 S STATE ST UNIT 108
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-7402
Mailing Address - Country:US
Mailing Address - Phone:386-313-5911
Mailing Address - Fax:
Practice Address - Street 1:250 AVENUE K SW
Practice Address - Street 2:SUITE 105
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3914
Practice Address - Country:US
Practice Address - Phone:863-268-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5122237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist