Basic Information
| Provider Information | |||||||||
| NPI: | 1477518975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOYAL | ||||||||
| FirstName: | SUPRIYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 LAKESIDE AVE E | ||||||||
| Address2: | STE 1200 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441141172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164795248 | ||||||||
| FaxNumber: | 2164795554 | ||||||||
| Practice Location | |||||||||
| Address1: | 12301 SNOW RD | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441301002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165247377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 35-095149 | OH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 2042398 | 05 | MA | MEDICAID |