Provider Demographics
NPI:1033141726
Name:GOLDMAN, GREGORY IRA (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:IRA
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1410
Mailing Address - Country:US
Mailing Address - Phone:845-534-2424
Mailing Address - Fax:845-534-0044
Practice Address - Street 1:10 ELM ST
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1410
Practice Address - Country:US
Practice Address - Phone:845-534-2424
Practice Address - Fax:845-534-0044
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143673207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01101940Medicaid
NY34E011Medicare ID - Type UnspecifiedEMPIRE MEDICARE SERVICES
NY01101940Medicaid