Healthcare Provider Details

I. General information

NPI: 1215124169
Provider Name (Legal Business Name): MARTIN B. GRESAK , O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 JEFFERSON AVE
MOUNDSVILLE WV
26041-1639
US

IV. Provider business mailing address

301 JEFFERSON AVE
MOUNDSVILLE WV
26041
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-2590
  • Fax:
Mailing address:
  • Phone: 304-845-2590
  • Fax:

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: MARTIN B GRESAK
Title or Position: OWNER
Credential: OD
Phone: 304-599-2828