Healthcare Provider Details

I. General information

NPI: 1932938883
Provider Name (Legal Business Name): JENNIFER GRACE LE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W 42ND ST
NEW YORK NY
10036-8005
US

IV. Provider business mailing address

467 COLUMBUS AVE APT 5A
NEW YORK NY
10024-5165
US

V. Phone/Fax

Practice location:
  • Phone: 212-938-4001
  • Fax:
Mailing address:
  • Phone: 909-544-9091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number010002
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: