Provider Demographics
NPI:1073884912
Name:GOLIBERSUCH, ALLEN M
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:M
Last Name:GOLIBERSUCH
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 1:12444 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14004-9529
Mailing Address - Country:US
Mailing Address - Phone:716-937-8888
Mailing Address - Fax:716-937-8889
Practice Address - Street 1:12444 BROADWAY ST.
Practice Address - Street 2:
Practice Address - City:ALDEN
Practice Address - State:NY
Practice Address - Zip Code:14004
Practice Address - Country:US
Practice Address - Phone:716-937-8888
Practice Address - Fax:716-937-8889
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY8737156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician