Provider Demographics
NPI:1417952037
Name:GRESAK, MARTIN B (OD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:B
Last Name:GRESAK
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 1:918 CHESTNUT RIDGE RD
Mailing Address - Street 2:STE 7
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2822
Mailing Address - Country:US
Mailing Address - Phone:304-599-2828
Mailing Address - Fax:304-599-7545
Practice Address - Street 1:918 CHESTNUT RIDGE RD
Practice Address - Street 2:STE 7
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2822
Practice Address - Country:US
Practice Address - Phone:304-599-2828
Practice Address - Fax:304-599-7545
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV748-OD152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV111052OtherEYE-MED
WV44711OtherDAVIS VISION
WV0577680001OtherDEMERC
WVWV1285189OtherFUNDS/UMWA
WV1417952037Medicare NSC
WVWV1285189OtherFUNDS/UMWA