Provider Demographics
NPI:1508415126
Name:GREDZIK, JACOB ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANDREW
Last Name:GREDZIK
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 1:2828 ALMOND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4710
Mailing Address - Country:US
Mailing Address - Phone:215-500-9153
Mailing Address - Fax:
Practice Address - Street 1:2828 ALMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4710
Practice Address - Country:US
Practice Address - Phone:215-500-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist