Healthcare Provider Details

I. General information

NPI: 1750468435
Provider Name (Legal Business Name): THEODORE GOLDBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MEDICAL DR
PORT JEFFERSON STATION NY
11776-1588
US

IV. Provider business mailing address

22 WATERVILLE RD
AVON CT
06001-2066
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number114421
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number114421
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number114421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: