Provider Demographics
NPI:1689640575
Name:OMALLEY DICKINSON, GRACE M (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:M
Last Name:OMALLEY DICKINSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:260 E MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-265-8780
Mailing Address - Fax:631-265-8521
Practice Address - Street 1:186 OLD TOWN RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5013
Practice Address - Country:US
Practice Address - Phone:631-283-3533
Practice Address - Fax:631-287-0571
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-12-30
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Provider Licenses
StateLicense IDTaxonomies
NY151395207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4085670001Medicare NSC
NYA400052788Medicare PIN
NY43D651Medicare PIN
NYA100052790Medicare PIN
NYB14524Medicare UPIN