Provider Demographics
NPI:1720574759
Name:GRYNYK, BOGDAN
Entity Type:Individual
Prefix:
First Name:BOGDAN
Middle Name:
Last Name:GRYNYK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 LONGBOAT KEY LN APT 304
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2756
Mailing Address - Country:US
Mailing Address - Phone:153-838-6173
Mailing Address - Fax:
Practice Address - Street 1:10934 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:CARROLLWOOD
Practice Address - State:FL
Practice Address - Zip Code:33618-4100
Practice Address - Country:US
Practice Address - Phone:813-559-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002701152W00000X
FLOPC5640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist