Provider Demographics
NPI:1083927149
Name:GOLDBERG, CARLY M (OD)
Entity Type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:M
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:63 SHAKER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1030
Mailing Address - Country:US
Mailing Address - Phone:212-832-9228
Mailing Address - Fax:212-751-9482
Practice Address - Street 1:550 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7369
Practice Address - Country:US
Practice Address - Phone:212-832-9228
Practice Address - Fax:212-751-9482
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY007623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program