Provider Demographics
NPI:1699714402
Name:GOLDBERG, JOEL SAMUEL (DO)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:SAMUEL
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 CHICHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-3138
Mailing Address - Country:US
Mailing Address - Phone:610-494-4422
Mailing Address - Fax:
Practice Address - Street 1:4015 CHICHESTER AVE
Practice Address - Street 2:
Practice Address - City:BOOTHWYN
Practice Address - State:PA
Practice Address - Zip Code:19061-3138
Practice Address - Country:US
Practice Address - Phone:610-494-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004415L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016128870002Medicaid
PA0016128870002Medicaid
PA021221Medicare PIN