Healthcare Provider Details

I. General information

NPI: 1336190552
Provider Name (Legal Business Name): MARAT GOLDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901
US

IV. Provider business mailing address

PO BOX 1524
AUGUSTA GA
30903-1524
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-7263
  • Fax: 706-774-7230
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number068171
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: