Healthcare Provider Details

I. General information

NPI: 1417952037
Provider Name (Legal Business Name): MARTIN B GRESAK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 CHESTNUT RIDGE RD STE 7
MORGANTOWN WV
26505-2822
US

IV. Provider business mailing address

918 CHESTNUT RIDGE RD STE 7
MORGANTOWN WV
26505-2822
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-2828
  • Fax: 304-599-7545
Mailing address:
  • Phone: 304-599-2828
  • Fax: 304-599-7545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number748-OD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: