Healthcare Provider Details

I. General information

NPI: 1699772483
Provider Name (Legal Business Name): LAWRENCE S GOLDBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 BELFORT RD SECOND FLOOR
JACKSONVILLE FL
32256-6004
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-7205
  • Fax: 904-396-4047
Mailing address:
  • Phone: 904-398-3262
  • Fax: 904-265-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0032734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: