Provider Demographics
NPI:1316146673
Name:GOODMAN, STEVEN I (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:I
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 ROUTE 112 STE A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3654
Mailing Address - Country:US
Mailing Address - Phone:631-758-5575
Mailing Address - Fax:631-758-5579
Practice Address - Street 1:1643 ROUTE 112 STE A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3654
Practice Address - Country:US
Practice Address - Phone:631-758-5575
Practice Address - Fax:631-758-5579
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01224079Medicaid
NYA400005462Medicare PIN
NY01224079Medicaid
U10237Medicare UPIN