Provider Demographics
NPI:1710045497
Name:GOLDBERG, SHIRA SIMONE (OD)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:SIMONE
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 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6509
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:300 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:GARWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07027-1312
Practice Address - Country:US
Practice Address - Phone:908-789-0101
Practice Address - Fax:908-789-1938
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00594200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJV02152Medicare UPIN
NJ084992CQTMedicare ID - Type UnspecifiedMEDICARE