Basic Information
| Provider Information | |||||||||
| NPI: | 1760559116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 31852 COAST HWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAGUNA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926516764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494991389 | ||||||||
| FaxNumber: | 9494995689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 20A5649 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207ND0900X | 20A5649 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X | 20A5649 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | 20A5649 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.