Provider Demographics
NPI:1174836241
Name:MARC A GOLDBERG MD PC
Entity type:Organization
Organization Name:MARC A GOLDBERG MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-712-3256
Mailing Address - Street 1:2000 S WHEELING AVE
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5649
Mailing Address - Country:US
Mailing Address - Phone:918-712-3256
Mailing Address - Fax:918-712-3263
Practice Address - Street 1:2000 S WHEELING AVE
Practice Address - Street 2:SUITE 1010
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5649
Practice Address - Country:US
Practice Address - Phone:918-712-3256
Practice Address - Fax:918-712-3263
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARC A GOLDBERG, MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-19
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK332H0000X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100198360AMedicaid
OK6446290001Medicare NSC
OKE83602Medicare UPIN