Provider Demographics
NPI:1467611228
Name:JACK FRIED, OD, PC
Entity Type:Organization
Organization Name:JACK FRIED, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-482-0129
Mailing Address - Street 1:64 MIDDLE NECK RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2357
Mailing Address - Country:US
Mailing Address - Phone:516-482-0129
Mailing Address - Fax:516-829-3126
Practice Address - Street 1:64 MIDDLE NECK RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2357
Practice Address - Country:US
Practice Address - Phone:516-482-0129
Practice Address - Fax:516-829-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5890152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400000564Medicare PIN
NY6340120001Medicare NSC