MEDICARE: DR. ILYA GINZBURG O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC5199	FL

General Provider Information

NPI Number	:	1558711192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILYA GINZBURG O.D.

Provider Business Mailing Address
First Line	:	1777 W 49TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-2936
Country	:	US
Telephone Number	:	305-825-7227
Fax Number	:	305-825-7233

Provider Business Practice Location Address
First Line	:	4975 SW 148TH AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33330-2419
Country	:	US
Telephone Number	:	267-307-2098
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2016
Last Update Date	:	10/02/2019

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