Provider Demographics
NPI:1447348826
Name:GOLDBERG, BRADLEY GORDON (MD)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:GORDON
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:11 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539
Mailing Address - Country:US
Mailing Address - Phone:912-384-2500
Mailing Address - Fax:912-383-6788
Practice Address - Street 1:2010 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2230
Practice Address - Country:US
Practice Address - Phone:912-384-2500
Practice Address - Fax:912-383-6788
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040079207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA138903OtherPEACHSTATE
GA700394OtherBCBS
GA000741694DMedicaid
GADH1281OtherRAILROAD MEDICARE - GROUP #
GA040079OtherGA LICENSE
GA040079OtherMEDICAL LICENSE
GA341191OtherWELLCARE OF GA
GAP00726008OtherRAILROAD MEDICARE - PTAN
GA11D0941435OtherCLIA
GA11D0941435OtherCLIA
GA341191OtherWELLCARE OF GA
GABG5301318OtherDEA
GA040079OtherGA LICENSE