Healthcare Provider Details

I. General information

NPI: 1598324188
Provider Name (Legal Business Name): JACKSON LANE GOLDBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10075 S JOG RD STE 203
BOYNTON BEACH FL
33437-3536
US

IV. Provider business mailing address

10075 S JOG RD STE 203
BOYNTON BEACH FL
33437-3536
US

V. Phone/Fax

Practice location:
  • Phone: 561-767-9999
  • Fax: 855-699-3535
Mailing address:
  • Phone: 561-767-9999
  • Fax: 855-699-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME165541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: