Provider Demographics
NPI:1164728952
Name:JOHN M. BRZEZICKI, JR., O.D.
Entity Type:Organization
Organization Name:JOHN M. BRZEZICKI, JR., O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MYRON
Authorized Official - Last Name:BRZEZICKI
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:716-662-4525
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTU002605-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY441540262OtherRAILROAD MEDICARE
NY00654784Medicaid
NY00654784Medicaid
NY441540262OtherRAILROAD MEDICARE