Healthcare Provider Details

I. General information

NPI: 1649428970
Provider Name (Legal Business Name): GREGORY M NEW OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 16TH ST STE 100
MOLINE IL
61265-7068
US

IV. Provider business mailing address

2921 ERIE BLVD E MASS OPTOMETRIC ASSOCIATES, P.C.
SYRACUSE NY
13224-1430
US

V. Phone/Fax

Practice location:
  • Phone: 309-764-0444
  • Fax: 978-670-7778
Mailing address:
  • Phone: 315-446-3145
  • Fax: 315-445-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4703
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: