Healthcare Provider Details

I. General information

NPI: 1154317121
Provider Name (Legal Business Name): RICHARD IAN GOLDBERGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5106 N ARMENIA AVE SUITE 4
TAMPA FL
33603-1433
US

IV. Provider business mailing address

5106 N ARMENIA AVE SUITE 4
TAMPA FL
33603-1433
US

V. Phone/Fax

Practice location:
  • Phone: 813-875-0074
  • Fax: 813-878-0186
Mailing address:
  • Phone: 813-875-0074
  • Fax: 813-878-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME34601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: