Provider Demographics
NPI:1154349322
Name:GOLDBERG, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5701 W 119TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3722
Mailing Address - Country:US
Mailing Address - Phone:913-345-8500
Mailing Address - Fax:913-345-3784
Practice Address - Street 1:5701 W 119TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3722
Practice Address - Country:US
Practice Address - Phone:913-345-8500
Practice Address - Fax:913-345-3784
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS422340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100003160OtherRAILROAD MEDICARE
KS100127110AMedicaid
MO200300509Medicaid
KS709373OtherAETNA
KS431207857OtherUNITED HEALTHCARE
MO17355020OtherBLUE CROSS BLUE SHIELD
KS709373OtherAETNA
MO200300509Medicaid