Provider Demographics
NPI:1750318226
Name:GOLDTHORPE, JEFFRY S (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:S
Last Name:GOLDTHORPE
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 1:130 HENRY DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1105
Mailing Address - Country:US
Mailing Address - Phone:608-742-7050
Mailing Address - Fax:
Practice Address - Street 1:130 HENRY DRIVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1105
Practice Address - Country:US
Practice Address - Phone:608-742-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2720152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38604100Medicaid
WI38604100Medicaid