Provider Demographics
NPI:1063606796
Name:FRED E. GOLDBERG O.D., F.A.A.O., PC
Entity type:Organization
Organization Name:FRED E. GOLDBERG O.D., F.A.A.O., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:703-893-2020
Mailing Address - Street 1:1340 OLD CHAIN BRIDGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3909
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:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3909
Practice Address - Country:US
Practice Address - Phone:703-893-2020
Practice Address - Fax:703-893-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0603000099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00402Medicare PIN
VAT31067Medicare UPIN
G00402Medicare PIN
VAU80918Medicare UPIN
VA0871890001Medicare PIN