Provider Demographics
NPI:1194391243
Name:GRYNYK, IVANNA STEPANIVNA (OD)
Entity Type:Individual
Prefix:DR
First Name:IVANNA
Middle Name:STEPANIVNA
Last Name:GRYNYK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8458 PARTRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 MARGARET ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1755
Practice Address - Country:US
Practice Address - Phone:518-566-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2800152W00000X
NYTUV009521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07104158Medicaid