Provider Demographics
NPI:1700804366
Name:GOLDBERG, MARK CHARLES (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
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 1:4790 E CAMP LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1275
Mailing Address - Country:US
Mailing Address - Phone:520-319-5922
Mailing Address - Fax:520-319-6128
Practice Address - Street 1:4790 E CAMP LOWELL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1275
Practice Address - Country:US
Practice Address - Phone:520-319-5922
Practice Address - Fax:520-319-6128
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18426207RC0000X, 207RI0011X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100462Medicaid
AZ62929Medicare ID - Type Unspecified
AZ100462Medicaid