Provider Demographics
NPI:1265658637
Name:GRACZYK, LINDA DIANE (ABOC)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:DIANE
Last Name:GRACZYK
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E BROWARD BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2008
Mailing Address - Country:US
Mailing Address - Phone:954-764-6962
Mailing Address - Fax:954-524-9400
Practice Address - Street 1:800 E BROWARD BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2008
Practice Address - Country:US
Practice Address - Phone:954-764-6962
Practice Address - Fax:954-524-9400
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO1726156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician