Provider Demographics
NPI:1972618510
Name:GOLDBERG, ELLICE KAY (DO)
Entity type:Individual
Prefix:
First Name:ELLICE
Middle Name:KAY
Last Name:GOLDBERG
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 E LOWRY BLVD STE 255
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7121
Mailing Address - Country:US
Mailing Address - Phone:720-321-3581
Mailing Address - Fax:720-321-3582
Practice Address - Street 1:8101 E LOWRY BLVD STE 255
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-7121
Practice Address - Country:US
Practice Address - Phone:720-321-3581
Practice Address - Fax:720-321-3582
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27685204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCE9318Medicare ID - Type Unspecified
COD24988Medicare UPIN