=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205811460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYRON D GOLDBERG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2005
-----------------------------------------------------
Last Update Date | 10/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5001 GOODRIDGE AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10471-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-453-1583
-----------------------------------------------------
Fax | 718-549-1089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5001 GOODRIDGE AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10471-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-453-1583
-----------------------------------------------------
Fax | 718-549-1089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 112414
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------