Healthcare Provider Details

I. General information

NPI: 1386938082
Provider Name (Legal Business Name): MATTHEW GOLDENBERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 WILSHIRE BLVD
SANTA MONICA CA
90403-4615
US

IV. Provider business mailing address

2708 WILSHIRE BLVD # 461
SANTA MONICA CA
90403-4706
US

V. Phone/Fax

Practice location:
  • Phone: 888-502-2120
  • Fax: 888-502-2120
Mailing address:
  • Phone: 424-276-0777
  • Fax: 888-502-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number145695
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number20A13416
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number145695
License Number StateAK
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A13416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: