Basic Information
| Provider Information | |||||||||
| NPI: | 1154329936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WOODS RD | ||||||||
| Address2: | TCC D376 | ||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144936616 | ||||||||
| FaxNumber: | 9144935827 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WOODS RD | ||||||||
| Address2: | TCC D376 | ||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144936616 | ||||||||
| FaxNumber: | 9144935827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 216875 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0050202 | 05 | NJ | MEDICAID | BG6766630 | 01 | DEA | OTHER | 60-216875 | 01 | NY | STATE LICENSE | OTHER |