Provider Demographics
NPI:1821048877
Name:BURKE, GRACE YVONNE (OD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:YVONNE
Last Name:BURKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9406
Mailing Address - Country:US
Mailing Address - Phone:315-788-6070
Mailing Address - Fax:315-788-1950
Practice Address - Street 1:1815 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9406
Practice Address - Country:US
Practice Address - Phone:315-788-6070
Practice Address - Fax:315-788-1950
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01780469Medicaid
NYBB3771Medicare ID - Type Unspecified
NYU37402Medicare UPIN