Healthcare Provider Details

I. General information

NPI: 1194563759
Provider Name (Legal Business Name): JONATHAN EZRA GOLDBERG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CLARKSON AVE
BROOKLYN NY
11203-2012
US

IV. Provider business mailing address

450 CLARKSON AVE
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 718-221-5148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberP129015
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: