Basic Information
| Provider Information | |||||||||
| NPI: | 1659378941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4525 3RD AVE SE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604128909 | ||||||||
| FaxNumber: | 3604128954 | ||||||||
| Practice Location | |||||||||
| Address1: | 4525 3RD AVE SE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604128909 | ||||||||
| FaxNumber: | 3604128954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00017869 | WA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1054675 | 05 | WA | MEDICAID |