Provider Demographics
NPI:1699240200
Name:GOLDBERG, JILL MEREDITH (OD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:MEREDITH
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4363 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2141
Mailing Address - Country:US
Mailing Address - Phone:248-674-4065
Mailing Address - Fax:248-673-4428
Practice Address - Street 1:4363 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2141
Practice Address - Country:US
Practice Address - Phone:248-674-4065
Practice Address - Fax:248-673-4428
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005164152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management