Provider Demographics
NPI:1083776983
Name:INNA GOLDBERG OD PC
Entity Type:Organization
Organization Name:INNA GOLDBERG OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:INNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-217-3797
Mailing Address - Street 1:544 MILFORD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4344
Mailing Address - Country:US
Mailing Address - Phone:847-217-3797
Mailing Address - Fax:
Practice Address - Street 1:2822 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1502
Practice Address - Country:US
Practice Address - Phone:773-338-1290
Practice Address - Fax:773-338-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209493Medicare ID - Type Unspecified
U64187Medicare UPIN
IL209494Medicare ID - Type Unspecified