Provider Demographics
NPI:1659495737
Name:GOLDBERG, IRA GARY (OD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:GARY
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:112 FULTON AVE # B
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-3752
Mailing Address - Country:US
Mailing Address - Phone:516-481-2020
Mailing Address - Fax:516-620-9064
Practice Address - Street 1:112 FULTON AVE # B
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3752
Practice Address - Country:US
Practice Address - Phone:516-481-2020
Practice Address - Fax:516-307-3305
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005281-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113265536OtherUNITEDHEALTHCARE
NY2160672OtherCIGNA
NYP2077105OtherOXFORD
NY113265536OtherHEALTHCAREPARTNEROFNY
NY01558676Medicaid
NY2146206OtherAETNA
NY146056OtherVYTRA
NY37514POtherHIP OF NEW YORK
NY6500906OtherGHI
NYC47481OtherEMPIRE BLUE CROSS BLUE SH
NY4C2296OtherHEALTHNET
NY113265536OtherTHE EMPIRE PLAN
NY113265536Other1199 WELFARE FUNDS
NYC47481OtherEMPIRE BLUE CROSS BLUE SH
NY113265536OtherUNITEDHEALTHCARE