MEDICARE: DONNA M GOENNER OPTICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156F00000X	Technician/Technologist	005432-1	NY

General Provider Information

NPI Number	:	1912141565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA M GOENNER OPTICIAN

Provider Business Mailing Address
First Line	:	750 MIDDLE COUNTRY RD
Second Line	:
City	:	MIDDLE ISLAND
State	:	NY
Zip	:	11953-2542
Country	:	US
Telephone Number	:	631-345-0065
Fax Number	:	631-345-0138

Provider Business Practice Location Address
First Line	:	750 MIDDLE COUNTRY RD
Second Line	:
City	:	MIDDLE ISLAND
State	:	NY
Zip	:	11953-2542
Country	:	US
Telephone Number	:	631-345-0065
Fax Number	:	631-345-0138

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	04/27/2009

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