Provider Demographics
NPI:1013903632
Name:KRZYZAK, RICHARD B (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:KRZYZAK
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 1:4871 W TAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-4819
Mailing Address - Country:US
Mailing Address - Phone:315-451-4600
Mailing Address - Fax:315-451-7710
Practice Address - Street 1:4871 W TAFT RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4819
Practice Address - Country:US
Practice Address - Phone:315-451-4600
Practice Address - Fax:315-451-7710
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00763433Medicaid
T89537Medicare UPIN
NY00763433Medicaid