Basic Information
Provider Information | |||||||||
NPI: | 1619061942 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDBERG | ||||||||
FirstName: | JOSHUA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 E ALTAMONTE DR | ||||||||
Address2: |   | ||||||||
City: | ALTAMONTE SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 327014802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073037283 | ||||||||
FaxNumber: | 4073030347 | ||||||||
Practice Location | |||||||||
Address1: | 601 E ALTAMONTE DR | ||||||||
Address2: |   | ||||||||
City: | ALTAMONTE SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 327014802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073037283 | ||||||||
FaxNumber: | 4073030347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 42813 | CO | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | MD.204457 | LA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | ME133602 | FL | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
ID | Type | State | Issuer | Description | 69074828 | 05 | CO |   | MEDICAID | 02975556 | 05 | MS |   | MEDICAID | 2141139 | 05 | LA |   | MEDICAID |