Provider Demographics
NPI:1689676728
Name:GNADT, GWENDA RENEE' (OD, MPH)
Entity Type:Individual
Prefix:DR
First Name:GWENDA
Middle Name:RENEE'
Last Name:GNADT
Suffix:
Gender:F
Credentials:OD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 SMITHTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2041
Mailing Address - Country:US
Mailing Address - Phone:631-588-5100
Mailing Address - Fax:631-588-5185
Practice Address - Street 1:271 SMITHTOWN BLVD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2041
Practice Address - Country:US
Practice Address - Phone:631-588-5100
Practice Address - Fax:631-588-5185
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYV5220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC45871Medicare PIN
NY31725Medicare UPIN