Provider Demographics
NPI:1356304067
Name:GOLDSMID, MICHAEL ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:GOLDSMID
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3750 SPORTS ARENA BLVD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5129
Mailing Address - Country:US
Mailing Address - Phone:619-224-2879
Mailing Address - Fax:619-224-1311
Practice Address - Street 1:3750 SPORTS ARENA BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5129
Practice Address - Country:US
Practice Address - Phone:619-224-2879
Practice Address - Fax:619-224-1311
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT-7475T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
T70203Medicare UPIN
T70203Medicare ID - Type Unspecified
CACY684AMedicare PIN
CACY686ZMedicare PIN