Provider Demographics
NPI:1679527907
Name:GOLDBERG, MARK E (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:GOLDBERG
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 1:2929 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5081
Mailing Address - Country:US
Mailing Address - Phone:954-752-9570
Mailing Address - Fax:954-752-9660
Practice Address - Street 1:2929 N UNIVERSITY DR
Practice Address - Street 2:SUITE 106
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5081
Practice Address - Country:US
Practice Address - Phone:954-752-9570
Practice Address - Fax:954-752-9660
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1134450001OtherPALMETTO SUPPLIER NUMBER
FLT84050Medicare UPIN
FL1134450001OtherPALMETTO SUPPLIER NUMBER