Basic Information
| Provider Information | |||||||||
| NPI: | 1699756726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDENBERG | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732901 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 N CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 70 (HALIFAX HEALTH CENTER FOR ADVANCED WOUND HEAL | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864254267 | ||||||||
| FaxNumber: | 3862584879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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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 | 213EP1101X | PO2530 | FL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0103X | PO2530 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 340118900 | 05 | FL | MEDICAID |