Provider Demographics
NPI:1396259362
Name:RONALD K GOLDBERG MD INC
Entity type:Organization
Organization Name:RONALD K GOLDBERG MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-462-9353
Mailing Address - Street 1:5565 GROSSMONT CENTER DR STE 455
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3073
Mailing Address - Country:US
Mailing Address - Phone:619-462-9353
Mailing Address - Fax:619-462-6935
Practice Address - Street 1:5565 GROSSMONT CENTER DR STE 455
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3073
Practice Address - Country:US
Practice Address - Phone:619-462-9353
Practice Address - Fax:619-462-6935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RONALD K GOLDBERG MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65437207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty