Provider Demographics
NPI:1285938415
Name:MARK E GOLDBERG OD PA
Entity type:Organization
Organization Name:MARK E GOLDBERG OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-752-9570
Mailing Address - Street 1:2929 N UNIVERSITY DR
Mailing Address - Street 2:STE 106
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5081
Mailing Address - Country:US
Mailing Address - Phone:954-752-9570
Mailing Address - Fax:954-600-9570
Practice Address - Street 1:2929 N UNIVERSITY DR
Practice Address - Street 2:STE 106
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5081
Practice Address - Country:US
Practice Address - Phone:954-752-9570
Practice Address - Fax:954-600-9570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1134450001Medicare NSC
FL19212Medicare PIN