Provider Demographics
NPI:1477514784
Name:HOLTZBERG, GARY ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALAN
Last Name:HOLTZBERG
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 1:20504 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2218
Mailing Address - Country:US
Mailing Address - Phone:718-464-2020
Mailing Address - Fax:718-464-2030
Practice Address - Street 1:20504 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2218
Practice Address - Country:US
Practice Address - Phone:718-464-2020
Practice Address - Fax:718-464-2020
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0049031152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01263827Medicaid
NYC84861Medicare ID - Type Unspecified
NY01263827Medicaid