Provider Demographics
NPI:1740236884
Name:GOLDBERG, BRADLEY DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DEAN
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 1:4363 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2141
Mailing Address - Country:US
Mailing Address - Phone:248-674-4065
Mailing Address - Fax:248-673-4428
Practice Address - Street 1:4363 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2141
Practice Address - Country:US
Practice Address - Phone:248-674-4065
Practice Address - Fax:248-673-4428
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901002961OtherMI OPTOMETRY LICENSE
MI0F366959901Medicaid
MI4901002961OtherMI OPTOMETRY LICENSE