Provider Demographics
NPI:1073584330
Name:GOLD, CHARLES I
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:I
Last Name:GOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4047 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1516
Mailing Address - Country:US
Mailing Address - Phone:212-927-2020
Mailing Address - Fax:212-923-5576
Practice Address - Street 1:4047 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1516
Practice Address - Country:US
Practice Address - Phone:212-927-2020
Practice Address - Fax:212-923-5576
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4232152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01027696Medicaid
NY01027696Medicaid
NYC32382Medicare PIN
NYC32381Medicare PIN