Provider Demographics
NPI:1447256714
Name:GOLDBERG, MARC EVAN (DPM)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:EVAN
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3408 OLANDWOOD CT
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1367
Mailing Address - Country:US
Mailing Address - Phone:301-924-5044
Mailing Address - Fax:301-924-5933
Practice Address - Street 1:3408 OLANDWOOD CT
Practice Address - Street 2:SUITE 204
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1367
Practice Address - Country:US
Practice Address - Phone:301-924-5044
Practice Address - Fax:301-924-5933
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01400213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
V00114Medicare UPIN
014358O05Medicare ID - Type Unspecified