Healthcare Provider Details

I. General information

NPI: 1790737989
Provider Name (Legal Business Name): KEITH R. GELB OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 RICHMOND AVE
STATEN ISLAND NY
10314-3918
US

IV. Provider business mailing address

2303 RICHMOND AVE
STATEN ISLAND NY
10314-3918
US

V. Phone/Fax

Practice location:
  • Phone: 718-982-9602
  • Fax:
Mailing address:
  • Phone: 718-982-9602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number4641
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: