Provider Demographics
NPI:1184729998
Name:GREDYSA, LESLAW J (MD)
Entity type:Individual
Prefix:DR
First Name:LESLAW
Middle Name:J
Last Name:GREDYSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MAIN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-369-8539
Mailing Address - Fax:631-369-5613
Practice Address - Street 1:31 MAIN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-369-8539
Practice Address - Fax:631-369-5613
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1751692086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY35085OtherVYTRA
NY01465594Medicaid
NY738310OtherAETNA
NY738310OtherAETNA
D93284Medicare UPIN