Provider Demographics
NPI:1528063344
Name:GOLDBERG, BARRY EDWARD (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:EDWARD
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4910
Mailing Address - Country:US
Mailing Address - Phone:631-376-4098
Mailing Address - Fax:631-376-3547
Practice Address - Street 1:1111 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4910
Practice Address - Country:US
Practice Address - Phone:631-376-4098
Practice Address - Fax:631-376-3547
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1803842080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01593315Medicaid
NY17L631OtherBLUE CROSS BLUE SHIELD
NY86769OtherVYTRA HEALTHCARE
NYS58003OtherSUFFOLK HEALTH PLAN
NY2101425OtherGHI
NY529661OtherAETNA MANAGED CARE
NY940143OtherCHAMPUS
NY1C2998OtherHEALTHNET
NY040426010631OtherFIDELIS
NYAG48955OtherMDNY HEALTHCARE
NY010180384NY01OtherANTHEM HEALTH
NY5737050OtherAETNA/US HEALTHCARE
NYDS691OtherOXFORD HEALTH PLAN
NYAG48955OtherMDNY HEALTHCARE
NY17L633Medicare ID - Type UnspecifiedMEDICARE PROVIDER #