Healthcare Provider Details

I. General information

NPI: 1528063344
Provider Name (Legal Business Name): BARRY EDWARD GOLDBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MONTAUK HWY
WEST ISLIP NY
11795-4910
US

IV. Provider business mailing address

1111 MONTAUK HWY
WEST ISLIP NY
11795-4910
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-4098
  • Fax: 631-376-3547
Mailing address:
  • Phone: 631-376-4098
  • Fax: 631-376-3547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number180384
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: