Provider Demographics
NPI:1528121803
Name:DARRYL T GOLDBERG MD PC
Entity type:Organization
Organization Name:DARRYL T GOLDBERG MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:WISKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-398-2525
Mailing Address - Street 1:30301 WOODWARD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0981
Mailing Address - Country:US
Mailing Address - Phone:248-398-2525
Mailing Address - Fax:248-398-9286
Practice Address - Street 1:30301 WOODWARD AVE STE 101
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0981
Practice Address - Country:US
Practice Address - Phone:248-398-2525
Practice Address - Fax:248-398-9286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK051524156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180F375320OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI3117704Medicaid
MI101836OtherGREAT LAKES HEALTH PLAN
MI180F375320OtherBLUE CARE NETWORK
MI4237942OtherDETROIT MEDICAL CENTER
MI180F375320OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIA73386Medicare UPIN
MIE89376Medicare UPIN
MI0308390001Medicare NSC
MI180023701Medicare PIN
MI0P57060Medicare PIN