Provider Demographics
NPI:1194815316
Name:GORELICK, PHYLLIS (OD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
Last Name:GORELICK
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 1:1953 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2820
Mailing Address - Country:US
Mailing Address - Phone:516-864-6298
Mailing Address - Fax:
Practice Address - Street 1:159-03 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434
Practice Address - Country:US
Practice Address - Phone:855-423-3700
Practice Address - Fax:631-499-3062
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUT004997-1152W00000X
NYTUV004997-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist