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General NPI Number Information
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NPI Number | 1215124169
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Entity Type | Organization
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Legal Business Name | MARTIN B. GRESAK , O.D.
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Dates
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Enumeration Date | 09/25/2007
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Last Update Date | 01/08/2008
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Provider Practice Location Address
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Address Line | 301 JEFFERSON AVE
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City | MOUNDSVILLE
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State | WV
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Zip | 26041-1639
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Country | US
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Telephone | 304-845-2590
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Fax |
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Provider Business Mailing Address
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Address Line | 301 JEFFERSON AVE
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City | MOUNDSVILLE
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State | WV
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Zip | 26041
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Country | US
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Telephone | 304-845-2590
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARTIN B GRESAK
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Credential | OD
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Telephone | 304-599-2828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 748-OD
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License Number State | WV
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