Provider Demographics
NPI:1114912573
Name:GOLDSMITH, TIMOTHY J (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:GOLDSMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-0261
Mailing Address - Country:US
Mailing Address - Phone:952-758-2080
Mailing Address - Fax:
Practice Address - Street 1:1101 1ST ST NE
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-2197
Practice Address - Country:US
Practice Address - Phone:952-758-2080
Practice Address - Fax:952-758-5922
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2401152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN951825800Medicaid
MNU33515Medicare UPIN
MN410001705Medicare PIN