Provider Demographics
NPI:1598827925
Name:GOTTFRIED, ABRAHAM JACOB (OD)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:JACOB
Last Name:GOTTFRIED
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 1:2856 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-2726
Mailing Address - Country:US
Mailing Address - Phone:718-585-5100
Mailing Address - Fax:718-292-0805
Practice Address - Street 1:2856 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-2726
Practice Address - Country:US
Practice Address - Phone:718-585-5100
Practice Address - Fax:718-292-0805
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0042891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00787426Medicaid
NYT49054Medicare UPIN
NY00787426Medicaid