Provider Demographics
NPI:1073612560
Name:BRZEZICKI, JOHN MYRON JR (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MYRON
Last Name:BRZEZICKI
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 W QUAKER ST
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2354
Mailing Address - Country:US
Mailing Address - Phone:716-662-4525
Mailing Address - Fax:716-662-4138
Practice Address - Street 1:6421 W QUAKER ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2354
Practice Address - Country:US
Practice Address - Phone:716-662-4525
Practice Address - Fax:716-662-4138
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00654751Medicaid
NYT25959Medicare UPIN
NY0536870001Medicare NSC