Healthcare Provider Details

I. General information

NPI: 1346353059
Provider Name (Legal Business Name): HEIDI GOLDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 SEMINOLE BLVD STE 201
SEMINOLE FL
33772-2562
US

IV. Provider business mailing address

15809 PENNINGTON RD
TAMPA FL
33624-1582
US

V. Phone/Fax

Practice location:
  • Phone: 727-393-6881
  • Fax:
Mailing address:
  • Phone: 813-960-7841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0053509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: