Provider Demographics
NPI:1760423321
Name:BARUCH, JEFFREY DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:BARUCH
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 1:612 CORPORATE WAY STE 2M
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2027
Mailing Address - Country:US
Mailing Address - Phone:718-362-1405
Mailing Address - Fax:718-414-1651
Practice Address - Street 1:647 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-3505
Practice Address - Country:US
Practice Address - Phone:718-362-1405
Practice Address - Fax:516-565-6272
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004881152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X
NYTUVOO4881-1152W00000X
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
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01147864Medicaid
U06385Medicare UPIN
NYC45042Medicare ID - Type Unspecified
NY01147864Medicaid
NY03009Medicare PIN
NY0630460001Medicare NSC
NY410041218Medicare PIN