Provider Demographics
NPI:1558711192
Name:GINZBURG, ILYA (OD)
Entity Type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:GINZBURG
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 1:1777 W 49TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2936
Mailing Address - Country:US
Mailing Address - Phone:305-825-7227
Mailing Address - Fax:305-825-7233
Practice Address - Street 1:4975 SW 148TH AVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-2419
Practice Address - Country:US
Practice Address - Phone:267-307-2098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty