Provider Demographics
NPI:1629056783
Name:DOZACK, DAVID P (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:DOZACK
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 1:470 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2529
Mailing Address - Country:US
Mailing Address - Phone:607-734-1679
Mailing Address - Fax:607-732-5549
Practice Address - Street 1:470 W WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-2529
Practice Address - Country:US
Practice Address - Phone:607-734-1679
Practice Address - Fax:607-732-5549
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-08
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003970152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT26540Medicare UPIN
NY0133510001Medicare NSC
NY38425BMedicare ID - Type Unspecified