Healthcare Provider Details

I. General information

NPI: 1841523677
Provider Name (Legal Business Name): STACEY P GOLDSTEIN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512-A EAST FOWLER AVE
TAMPA FL
33612-5416
US

IV. Provider business mailing address

5607 JOHNS RD
TAMPA FL
33634-4499
US

V. Phone/Fax

Practice location:
  • Phone: 813-971-0471
  • Fax: 813-971-5864
Mailing address:
  • Phone: 813-885-3937
  • Fax: 813-884-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 4440
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: