Provider Demographics
NPI:1306935432
Name:GOLDBERG, MARK KING (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KING
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5638 OVERBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1316
Mailing Address - Country:US
Mailing Address - Phone:215-877-5770
Mailing Address - Fax:610-660-9755
Practice Address - Street 1:5638 OVERBROOK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1316
Practice Address - Country:US
Practice Address - Phone:215-877-5770
Practice Address - Fax:610-660-9755
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002176L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT72850Medicare UPIN
PA161901Medicare ID - Type Unspecified