Provider Demographics
NPI:1154390326
Name:GOLDBERG, MAYA A (NP)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:A
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 FROST ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2247
Mailing Address - Country:US
Mailing Address - Phone:781-248-7240
Mailing Address - Fax:
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-724-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254568363L00000X, 363LA2200X
MARN254568207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA27837OtherHARVARD PILGRIM
MA0798983Medicaid
MANP4930OtherBLUE CROSS
MAQ37259Medicare UPIN
MANP4930Medicare ID - Type Unspecified