Healthcare Provider Details

I. General information

NPI: 1720574759
Provider Name (Legal Business Name): BOGDAN GRYNYK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10934 N DALE MABRY HWY
CARROLLWOOD FL
33618-4100
US

IV. Provider business mailing address

11020 LONGBOAT KEY LN APT 304
TAMPA FL
33626-2756
US

V. Phone/Fax

Practice location:
  • Phone: 813-559-4990
  • Fax:
Mailing address:
  • Phone: 153-838-6173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002701
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5640
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: