Healthcare Provider Details

I. General information

NPI: 1720045834
Provider Name (Legal Business Name): JEFFREY M GOLDBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 DUTCHMANS LN STE 405
LOUISVILLE KY
40207-4723
US

IV. Provider business mailing address

100 E LIBERTY ST SUITE 800
LOUISVILLE KY
40202-1434
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-3366
  • Fax: 502-899-6686
Mailing address:
  • Phone: 502-587-4672
  • Fax: 502-587-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number37030
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number37030
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number37030
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: