Provider Demographics
NPI:1528172236
Name:GOLDENBERG, BRUCE D (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:GOLDENBERG
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 1:5425 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3404
Mailing Address - Country:US
Mailing Address - Phone:773-725-7557
Mailing Address - Fax:773-794-0138
Practice Address - Street 1:5425 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3404
Practice Address - Country:US
Practice Address - Phone:773-725-7557
Practice Address - Fax:773-794-0138
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC46133Medicare UPIN
ILL34411Medicare PIN