Provider Demographics
NPI:1518923556
Name:GOLDMAN, JEREMY P (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:P
Last Name:GOLDMAN
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 1:12621 WATERSPOUT CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1028
Mailing Address - Country:US
Mailing Address - Phone:443-621-0756
Mailing Address - Fax:
Practice Address - Street 1:12621 WATERSPOUT CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-1028
Practice Address - Country:US
Practice Address - Phone:443-621-0756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1949152W00000X
NYV6589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD016072500Medicaid
DCP00602581OtherRAILROAD
MDP00680168OtherRAILROAD
MD133772ZALTMedicare PIN
DCP00602581OtherRAILROAD
MD412P812GMedicare PIN