Healthcare Provider Details

I. General information

NPI: 1760423321
Provider Name (Legal Business Name): JEFFREY DAVID BARUCH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 HOWARD AVE
WEST HEMPSTEAD NY
11552-3505
US

IV. Provider business mailing address

612 CORPORATE WAY STE 2M
VALLEY COTTAGE NY
10989-2027
US

V. Phone/Fax

Practice location:
  • Phone: 718-362-1405
  • Fax: 516-565-6272
Mailing address:
  • Phone: 718-362-1405
  • Fax: 718-414-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004881
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV004881
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberTUV004881
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTUV004881
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberTUV004881
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUVOO4881-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: