Provider Demographics
NPI:1902914435
Name:GOLDBERG, JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 W HENRIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5009
Mailing Address - Country:US
Mailing Address - Phone:917-859-7257
Mailing Address - Fax:808-731-8479
Practice Address - Street 1:83 W HENRIETTA AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5009
Practice Address - Country:US
Practice Address - Phone:917-859-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2024-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1507592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB78367Medicare UPIN
NY62D541Medicare ID - Type Unspecified