=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881874949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK C GOLDBERG, MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2007
-----------------------------------------------------
Last Update Date | 05/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4790 E CAMP LOWELL DR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-1275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-319-5922
-----------------------------------------------------
Fax | 520-319-6128
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4790 E CAMP LOWELL DR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-1275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-319-5922
-----------------------------------------------------
Fax | 520-319-6128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARK C GOLDBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 520-319-5922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 18426
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------