Provider Demographics
NPI:1629440870
Name:GOLDMAN, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12960 W STATE ROAD 84
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-3306
Mailing Address - Country:US
Mailing Address - Phone:954-424-3130
Mailing Address - Fax:954-835-2442
Practice Address - Street 1:12960 WEST STATE ROAD 84
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33325
Practice Address - Country:US
Practice Address - Phone:954-424-3130
Practice Address - Fax:954-835-2442
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3856156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic