Provider Demographics
NPI:1629205604
Name:TIMOTHY J. GRACE O.D.,P.C.
Entity type:Organization
Organization Name:TIMOTHY J. GRACE O.D.,P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:716-488-1148
Mailing Address - Street 1:548 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-4733
Mailing Address - Country:US
Mailing Address - Phone:716-488-1148
Mailing Address - Fax:716-488-0047
Practice Address - Street 1:548 W 3RD ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-4733
Practice Address - Country:US
Practice Address - Phone:716-488-1148
Practice Address - Fax:716-488-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004521-1152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU00129Medicare UPIN