Basic Information
| Provider Information | |||||||||
| NPI: | 1336190552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDENBERG | ||||||||
| FirstName: | MARAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1524 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309031524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067747263 | ||||||||
| FaxNumber: | 7067747230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 WALTON WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067747263 | ||||||||
| FaxNumber: | 7067747230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 05/28/2018 | ||||||||
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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 | 2086S0129X | 068171 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003126148B | 05 | GA | MEDICAID | 003126148A | 05 | GA | MEDICAID |