Healthcare Provider Details

I. General information

NPI: 1336295955
Provider Name (Legal Business Name): GARY GOLDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E 98TH ST FL 5
NEW YORK NY
10029-6501
US

IV. Provider business mailing address

245 EAST 87TH STREET, APT 10F
NEW YORK NY
10128
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-9065
  • Fax: 212-987-1197
Mailing address:
  • Phone: 917-209-9940
  • Fax: 212-987-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD66160
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number250770
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberD66160
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number250770
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: