Provider Demographics
NPI:1972560456
Name:GOLDBERG, PAUL MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MICHAEL
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 1:12300 BRIARBUSH LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1032
Mailing Address - Country:US
Mailing Address - Phone:301-670-8338
Mailing Address - Fax:301-670-8339
Practice Address - Street 1:1201 SEVEN LOCKS RD
Practice Address - Street 2:SUITE 216
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-2931
Practice Address - Country:US
Practice Address - Phone:301-670-8338
Practice Address - Fax:301-670-8339
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0032415207K00000X, 207KA0200X
VA0102036831207K00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
52-1744186OtherFEDERAL TAX ID
52-1744186OtherFEDERAL TAX ID
468425Medicare ID - Type Unspecified