Healthcare Provider Details

I. General information

NPI: 1194814624
Provider Name (Legal Business Name): DAVID ALAN GOLDENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 PARK AVE
PLAINFIELD NJ
07060-3010
US

IV. Provider business mailing address

1165 PARK AVE
PLAINFIELD NJ
07060-3010
US

V. Phone/Fax

Practice location:
  • Phone: 908-754-2992
  • Fax:
Mailing address:
  • Phone: 908-754-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA03837300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2088207
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: