Provider Demographics
NPI:1871660571
Name:GOLDBERG, FRED ELIAS (OD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:ELIAS
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1340 OLD CHAIN BRIDGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3955
Mailing Address - Country:US
Mailing Address - Phone:703-893-2020
Mailing Address - Fax:703-893-4757
Practice Address - Street 1:1340 OLD CHAIN BRIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3955
Practice Address - Country:US
Practice Address - Phone:703-893-2020
Practice Address - Fax:703-893-4757
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000055152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000Y91M02Medicare PIN
T31067Medicare UPIN