Healthcare Provider Details

I. General information

NPI: 1154352862
Provider Name (Legal Business Name): HARRY GOLDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 NAVARRE STREET
THOREAU NM
87323
US

IV. Provider business mailing address

PO BOX 358
CROWNPOINT NM
87313-0358
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-5291
  • Fax: 505-786-6440
Mailing address:
  • Phone: 505-786-5291
  • Fax: 505-786-6440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number21100
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: