Healthcare Provider Details

I. General information

NPI: 1992707491
Provider Name (Legal Business Name): STEVEN I GOODMAN OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1643 ROUTE 112 STE A
MEDFORD NY
11763-3654
US

IV. Provider business mailing address

1643 ROUTE 112 STE A
MEDFORD NY
11763-3654
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-5575
  • Fax: 631-758-5579
Mailing address:
  • Phone: 631-758-5575
  • Fax: 631-758-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT005113
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberVUT005113
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberVUT005113
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberVUT005113
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberVUT005113
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberVUT005113
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberVUT005113
License Number StateNY

VIII. Authorized Official

Name: DR. STEVEN I GOODMAN
Title or Position: DR.
Credential: O.D.
Phone: 631-758-5575