Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 34-00-2116G | OH |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 34-00-2116G | OH |
NPI | 1578563128 |
---|---|
Provider Name | David D Goldberg |
First Address | Moraine, OH 45439-1962 |
Second Address | Moraine, OH 45439-1962 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2005 |
Last Update Date | 16/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000226414 | ANTHEM (01) | OH |
0203998 | (05) | OH |
A74304 | (02) |