Provider Demographics
NPI:1730199068
Name:GOLDBERG, INNA (OD)
Entity type:Individual
Prefix:DR
First Name:INNA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4512
Mailing Address - Country:US
Mailing Address - Phone:773-743-4300
Mailing Address - Fax:773-743-5132
Practice Address - Street 1:6801 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4512
Practice Address - Country:US
Practice Address - Phone:773-743-4300
Practice Address - Fax:773-743-5132
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U64187Medicare UPIN
211840Medicare ID - Type Unspecified