Provider Demographics
NPI:1770576811
Name:GOLDSTEIN, MITCHELL FRANK (OD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:FRANK
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20901 LA QUESTA CT
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1234
Mailing Address - Country:US
Mailing Address - Phone:561-451-9837
Mailing Address - Fax:
Practice Address - Street 1:6300 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1906
Practice Address - Country:US
Practice Address - Phone:954-776-6055
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20113AMedicare ID - Type Unspecified