Provider Demographics
NPI:1992794663
Name:GOLDBERG, HARRIS IRA (DC)
Entity type:Individual
Prefix:DR
First Name:HARRIS
Middle Name:IRA
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1696 SE HILLMOOR DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7699
Mailing Address - Country:US
Mailing Address - Phone:772-335-3222
Mailing Address - Fax:772-335-3793
Practice Address - Street 1:1696 SE HILLMOOR DR
Practice Address - Street 2:STE C
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7699
Practice Address - Country:US
Practice Address - Phone:772-335-3222
Practice Address - Fax:772-335-3793
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH005283111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381-223500Medicaid
FL381-223500Medicaid
FL70885Medicare ID - Type Unspecified