Healthcare Provider Details

I. General information

NPI: 1285721886
Provider Name (Legal Business Name): MARK HOWARD GRISAR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 CENTRAL PARK AVE
YONKERS NY
10710-2828
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 914-961-1004
  • Fax: 914-961-7636
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT004040-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: