Provider Demographics
NPI:1518027028
Name:GOLDBERG, MARCY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARCY
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:11445 SUNSET HILLS ROAD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5276
Practice Address - Country:US
Practice Address - Phone:703-709-1500
Practice Address - Fax:703-709-1628
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1072152W00000X
VA0618000056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
006594M92Medicare ID - Type Unspecified
U83942Medicare UPIN