Provider Demographics
NPI:1992799464
Name:GOLDBERG, MARK S (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 AMBLER LN
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-1205
Mailing Address - Country:US
Mailing Address - Phone:732-583-4466
Mailing Address - Fax:732-583-1639
Practice Address - Street 1:4 AMBLER LN
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NJ
Practice Address - Zip Code:07747-1205
Practice Address - Country:US
Practice Address - Phone:732-583-4466
Practice Address - Fax:732-583-1639
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00206000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5481007Medicaid
NJGO673055Medicare PIN
NJ5523220001Medicare NSC
NJ5481007Medicaid