Healthcare Provider Details

I. General information

NPI: 1104319219
Provider Name (Legal Business Name): GERARD R D'AVERSA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E SUNRISE HWY STE 400
VALLEY STREAM NY
11581-1233
US

IV. Provider business mailing address

825 E GATE BLVD STE 111
GARDEN CITY NY
11530-2136
US

V. Phone/Fax

Practice location:
  • Phone: 516-374-4199
  • Fax: 516-295-5303
Mailing address:
  • Phone: 516-804-5200
  • Fax: 516-240-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number008756
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: