Provider Demographics
NPI:1285829630
Name:GOLDSTEIN, BERNARD
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 SPRING BEAUTY CT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-9505
Mailing Address - Country:US
Mailing Address - Phone:770-222-2296
Mailing Address - Fax:
Practice Address - Street 1:3608 SPRING BEAUTY CT
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-9505
Practice Address - Country:US
Practice Address - Phone:770-222-2296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA667152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU22430Medicare UPIN