Provider Demographics
NPI:1255643177
Name:GOFF, ADAM R (OD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:R
Last Name:GOFF
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:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-0013
Mailing Address - Country:US
Mailing Address - Phone:517-303-3652
Mailing Address - Fax:
Practice Address - Street 1:123 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4625
Practice Address - Country:US
Practice Address - Phone:517-303-3652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2016-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004627152W00000X
OHOPT.5943-THER152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0733500027Medicare NSC
MI0C97655Medicare PIN
1251300001Medicare NSC
1251300002Medicare NSC
M60150010Medicare PIN
MIM60130014Medicare PIN
MI1251300003Medicare NSC
MI0M60130Medicare PIN
0M60150Medicare PIN