Provider Demographics
NPI:1457429508
Name:SASARAK, GREGORY S (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:SASARAK
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 1:280 S LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6224
Mailing Address - Country:US
Mailing Address - Phone:440-365-9311
Mailing Address - Fax:
Practice Address - Street 1:280 S LOGAN ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6224
Practice Address - Country:US
Practice Address - Phone:440-365-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2642840Medicaid
OH2642840Medicaid
OHVO7452Medicare UPIN