Basic Information
Provider Information | |||||||||
NPI: | 1629041470 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDBERG | ||||||||
FirstName: | STANLEY | ||||||||
MiddleName: | JULIAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2701 E ELVIRA RD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857567124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206266508 | ||||||||
FaxNumber: | 5206266571 | ||||||||
Practice Location | |||||||||
Address1: | 535 N WILMOT RD | ||||||||
Address2: | SUITE #101 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206949988 | ||||||||
FaxNumber: | 5206949917 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2006 | ||||||||
LastUpdateDate: | 05/29/2013 | ||||||||
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 | 2080P0202X | 5943 | AZ | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.