Provider Demographics
NPI:1104204114
Name:GOLDBERG, JAN PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:JAN PAUL
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JP
Other - Middle Name:
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:816 ACOMA STREET
Mailing Address - Street 2:UNIT 1113
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4068
Mailing Address - Country:US
Mailing Address - Phone:303-912-4900
Mailing Address - Fax:
Practice Address - Street 1:816 ACOMA STREET
Practice Address - Street 2:UNIT 1113
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4068
Practice Address - Country:US
Practice Address - Phone:303-912-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1217157Medicaid
CO21715OtherCOLORADO LICENSE
CO21715OtherCOLORADO STATE LICENSE