1649428970 NPI number — GREGORY M NEW OD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649428970 NPI number — GREGORY M NEW OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEW
Provider First Name:
GREGORY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649428970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2921 ERIE BLVD E
Provider Second Line Business Mailing Address:
MASS OPTOMETRIC ASSOCIATES, P.C.
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13224-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-446-3145
Provider Business Mailing Address Fax Number:
315-445-7675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 16TH ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-7068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-764-0444
Provider Business Practice Location Address Fax Number:
978-670-7778
Provider Enumeration Date:
08/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4703 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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