Provider Demographics
NPI:1205843760
Name:GOLDBERG, MICHAEL J (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3332 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4402
Mailing Address - Country:US
Mailing Address - Phone:772-692-9526
Mailing Address - Fax:772-692-9472
Practice Address - Street 1:3332 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4402
Practice Address - Country:US
Practice Address - Phone:772-692-9526
Practice Address - Fax:772-692-9472
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL3709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY09809Medicare UPIN
FL45013ZMedicare ID - Type Unspecified