Healthcare Provider Details

I. General information

NPI: 1073735783
Provider Name (Legal Business Name): ROBERT GRZESIAK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 WALT WHITMAN RD # A
HUNTINGTON STATION NY
11746-4130
US

IV. Provider business mailing address

39 BALSAM DR
DIX HILLS NY
11746-7724
US

V. Phone/Fax

Practice location:
  • Phone: 631-351-5355
  • Fax:
Mailing address:
  • Phone: 631-423-7026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT-005977-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: