Provider Demographics
NPI:1063434371
Name:GOLDBERG, MARK N (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:N
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 1:857 NE 98 STREET
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2532
Mailing Address - Country:US
Mailing Address - Phone:305-557-3300
Mailing Address - Fax:305-756-9689
Practice Address - Street 1:296 NE 99TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2435
Practice Address - Country:US
Practice Address - Phone:305-557-3300
Practice Address - Fax:305-756-9689
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL269312084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049846700Medicaid
FL049846700Medicaid
FLD67242Medicare UPIN