Healthcare Provider Details

I. General information

NPI: 1710045497
Provider Name (Legal Business Name): SHIRA SIMONE GOLDBERG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTH AVE
GARWOOD NJ
07027-1312
US

IV. Provider business mailing address

11103 WEST AVE SUITE 6
SAN ANTONIO TX
78213-1370
US

V. Phone/Fax

Practice location:
  • Phone: 908-789-0101
  • Fax: 908-789-1938
Mailing address:
  • Phone: 210-524-6509
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00594200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: