Healthcare Provider Details

I. General information

NPI: 1114015690
Provider Name (Legal Business Name): MARK GOLDBERG C.P.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 TECHNOLOGY DR
EAST SETAUKET NY
11733-4000
US

IV. Provider business mailing address

9 TECHNOLOGY DR
EAST SETAUKET NY
11733-4000
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-6606
  • Fax: 631-941-3525
Mailing address:
  • Phone: 631-689-6606
  • Fax: 631-941-3525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: