Provider Demographics
NPI:1073735783
Name:GRZESIAK, ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:GRZESIAK
Suffix:
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 1:39 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7724
Mailing Address - Country:US
Mailing Address - Phone:631-423-7026
Mailing Address - Fax:
Practice Address - Street 1:160 WALT WHITMAN RD # A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4130
Practice Address - Country:US
Practice Address - Phone:631-351-5355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT-005977-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist