Provider Demographics
NPI:1770760852
Name:GOLDMAN, MICHAEL MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARK
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:24100 EL TORO RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637
Mailing Address - Country:US
Mailing Address - Phone:949-586-8980
Mailing Address - Fax:949-586-0624
Practice Address - Street 1:24100 EL TORO RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637
Practice Address - Country:US
Practice Address - Phone:949-586-8980
Practice Address - Fax:949-586-0624
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7956TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU78452Medicare UPIN