Provider Demographics
NPI:1578742839
Name:MARK GOLDBERG PROSTHETIC & ORTHOTIC LABS, INC.
Entity Type:Organization
Organization Name:MARK GOLDBERG PROSTHETIC & ORTHOTIC LABS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-689-6606
Mailing Address - Street 1:205 N BELLE MEAD RD STE 150
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3483
Mailing Address - Country:US
Mailing Address - Phone:631-689-6606
Mailing Address - Fax:631-941-3525
Practice Address - Street 1:205 N BELLE MEAD RD STE 150
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3483
Practice Address - Country:US
Practice Address - Phone:631-689-6606
Practice Address - Fax:631-941-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0107718Medicaid
NY0107718Medicaid